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It's like a scene from Jaws: just when 
you thought it was safe to go back in 
the water, your worst nightmare 
makes an unexpected return. 

For community pharmacy, it's the 
fear that a government agency will 
decide it's time to tinker again with 
control of entry (p5). 

So, seven years after its study 
of the pharmacy market, the OFT 
this week released an evaluation 
of the impact of the government's 
partial relaxation of control of 
entry in 2005. 

And (unsurprisingly) the report 
says that consumers have benefited 
from a greater choice of pharmacies 
and services, cheaper OTC medicines 
and improvements in waiting times, 
opening times and convenience. 
Although it's hard to put a final 
figure on it, the benefits could be 
£70m or more, claims the report. 

It's hard to argue against any 
positive consumer benefit - after 
all, community pharmacy is in the 
business of delivering patient 
benefits - but you have to wonder 
if the regulatory pain and upheaval 
the sector has been through in the 
past five years has been a 
worthwhile exercise. 

A more welcome finding would 
have been a significant increase in 
the number and diversity of local 
enhanced services (LES) provided by 
pharmacies. Such services could 
easily have demonstrated 
considerable knock-on patient and 
NHS benefits, far in excess of those 
listed in this latest report. 

But delve deep into this latest 

research and you find a survey which 
asked PCTs if the pharmacies that 
have opened since 2005 provide a 
higher or lower range and volume of 
LES than existing pharmacies. Two 
thirds of the 24 PCTs that responded 
said new providers were similar in 
output to existing pharmacies. 

Like the great white shark, the 
control of entry debate is never far 
from the surface, but the endless 
debates, tweaks and proposals have 
not brought the big rewards for 
either parties. And the latest idea to 
allow PCTs to set local dispensing 
fees (p5) is unlikely to be welcomed 
by PCTs or contractors. 

If this latest control of entry 
debate does little to lift your mood, 
then perhaps the view from the man 
who could potentially be England's 
next pharmacy minister is what 
pharmacists want to hear. Mark 
Simmonds' (p4) desire to accelerate 
the roll-out of additional pharmacy 
services and to see pharmacists 
working closer with CPs seems a far 
more productive solution to 
delivering patient benefits. 

Of course, in the run up to a 
general election, candidates will be 
on message and you have to take 
promises on trust. But now that 
the rollout of pharmaceutical 
needs assessments (PNAs) has put 
an end to the problem of what to do 
with control of entry, the only 
debate we should be having is how 
best patients can benefit from 
pharmacy services. 

Gary Paragpuri, Editor 

4 Jail threat lingers for single error 

5 PCT should set local dispensing fees 

6 GPhC OK for conscience clause 

8 Most pharmacists working longer hours 
10 Hostile verdict on GPhC standards 
12 Product and market news 
14 Xrayser and Sue Sharpe 
24 Classified 
30 Postscript 

17 Update: Managing patients on warfarin 

What to look out for and lifestyle advice 

19 Practical Approach 

Prescribing for hypertension 

20 Ethical Dilemma 

A request for a POM pack of EHC off script 

22 Category M Barometer 

Generic Eric reveals the 2010 second tariff details 

25 Careers 

Life as a network development manager 

© UBM Medica, Chemist+Druggist incorporating Retail Chemist, Pharmacy Update and Beauty Counter. Published Saturdays by UBM Medica, Ludgate House, 245 Blackfnars Road. London SET 9UY C + D online at Subscriptions: With C+D Monthly pricelist £250 (UK), without pncelist £205 (UK). ROW price £365. Circulation and subscription: UBM Information Ltd, Tower House, Sovereign Park. Lathkill St. 
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?ress, Queens Road, Ashford TN24 8HH Registered at the Post Office as a Newspaper. Volume 273 No 6740 



Jail fear remains as dispensing 
error review 'under consideration 1 

Protection deal promised in January still being debated by prosecutors 

Pharmacists are facing continued pressure waiting for the guidance to be approved 

Chris Chapman 

Pharmacists are still under threat of 
a jail term for a single dispensing 
error three months after promised 
protection was due. 

Speaking to C+D, the Crown 
Prosecution Service (CPS) said 
guidance to halt dispensing error 
prosecutions was "still being 
considered" by the director of public 
prosecutions. "It will take as long as 
it takes," a spokeswoman said. 
"These things can't be rushed and 
have to be done right." 

England's chief pharmacist Keith 
Ridge pledged the CPS guidance 
would arrive "early in the 
new year" at a meeting of the all- 
party pharmacy group (APPG) last 

Dr Ridge first announced 
prosecutors would be asked not to 
pursue one-off dispensing errors to 
the group last June. However, 
despite talks between the drugs 
watchdog and the CPS, the guidance 

was still awaiting approval, the DH 
confirmed on behalf of Dr Ridge. 

After prompting from C+D, the 
RPSCB pledged to investigate the 
situation with the CPS to find out 
progress on the guidance. 

The delay was met with 

frustration by grassroots 
pharmacists. Locum Graeme 
Stafford questioned whether the 
authorities understood the pressures 
pharmacists face daily. 

He said: "There doesn't seem to 
be any urgency, as they don't live 

with the pressure on a day-to- 
day basis." 

Amish Patel, of Hodgson 
Pharmacy, Dartford, told C+D the 
hold up was inevitable. 

"The delay was to be expected - 
anyone who thought it would be 
quicker was naive," he said. "It's 
moving in the right direction, it just 
needs to keep moving. It's out of 
pharmacy's hands." 

The CPS has faced mounting 
pressure to issue the guidance 
following the news Elizabeth Lee 
would appeal her conviction (C+D, 
March 6, p4). Mrs Lee was handed a 
three-month suspended sentence 
for a dispensing error last April 
despite bearing no responsibility for 
the patient's death. The case sparked 
calls for decriminalisation of errors. 

What's your view of the 
delay to the guidance? 


Conservatives promise faster service delivery 

Hark Simmonds: disappointed with patchy delivery of white paper reforms 

Watch C+D reporter Zoe Smeaton 
interview Conservative shadow health 
minister Mark Simmonds on what a 
Tory government would mean for the 

A Conservative government would 
look to "put their foot on the 
accelerator" to roll out additional 
community pharmacy services, 
shadow health minister Mark 
Simmonds has pledged. 

Pharmacists would have a 
significant part to play in 
commissioning primary care 
services, working alongside 
GPs leading the process, Mr 
Simmonds said. 

Speaking exclusively to C+D, 
Mr Simmonds said he had been 
disappointed with the patchy 
delivery of the pharmacy white 
paper so far, and would look to 
speed up progress on implementing 
the promised services. 

A Conservative government 
would ringfence NHS funding, he 
said, and look to make savings in 
areas such as administration and 
quangos. Some of the monies saved 
could be "refocused" back into 
frontline patient care and allocated 
for pharmacies providing the 
additional services, he added. 

Mr Simmonds acknowledged 
there had been friction between GPs 
and pharmacists in some areas but 
said: "I think what we must do is try 
to make sure that the interests of 
GPs and pharmacists are aligned to 
make sure that everybody is moving 
and working in the same direction 
for the maximum patient benefit." 

Mr Simmonds said he would like 
to see pharmacists co-ordinating 
their work with others in primary 
care, but warned that expanding 
their roles could be challenging. 

He said he would like to see 
more being made of MURs, with 
pharmacists perhaps even advising 
GPs as well. 

"I think there's a strong argument 
for pharmacy to provide advice not 
just for patients but also to GPs... to 
make sure patients are getting the 
appropriate drugs at the appropriate 
time," he said. ZS 

Read the full interview with Mark 
Simmonds in C+D's upcoming 
coverage of the general election 


Has relaxing control of entry delivered better pharmacies? 


PCTs should set local 
dispensing fees, says OFT 

Ruling comes as watchdog says easing entry rules benefited patients 

Jennifer Richardson 

PCTs should set dispensing fees 
locally, a report published by the 
competition watchdog has suggested. 

The proposal was made in an 
impact evaluation of 2005's 
relaxation of control of entry rules, 
including the 100-hour pharmacy 
exemption, which found the reforms 
had brought "significant benefits for 

Uniform remuneration across 
different local markets in England 
did not provide the "correct 
incentives" for market entry in at 

least some areas, said the report, 
produced for the Office of Fair 
Trading (OFT) by independent 
economic consultants DotEcon. 

It suggested that under 
pharmaceutical needs assessments 
(PNAs), which PCTs must publish by 
February next year, "it can be 
questioned whether, with careful 
design, the principle of locally 
specific payment terms. . . should not 
extend to dispensing services". 

Co-operative Pharmacy managing 
director John Nuttall reacted 
cautiously to the suggestion. "We 
need to wait for the cost of service 
inquiry to determine the cost of 

Deregulation: consumer gains while pharmacy pains since 2005 



£21 -68m gains in 
liability and 
nge of pharmacy 

£300m estimated 
shortfall in funding, 
says Co-op 

£5m saving in lower 
OTC prices 

* Source Evaluating the impact of the 2003 OFT study on the control 
of entry regulations in the retail pharmacies market, OFT (DotEcon) 

providing services to patients, and 
the structure of payments perhaps 
comes later," he told C+D. 

The NPA was less equivocal in its 
rejection of the idea. It said locally- 
determined fees would "build in 
cost and equity" and be "unlikely to 
provide an acceptable means to 
rational distribution of pharmacies" 

The impact evaluation found the 
2005 reforms had resulted in net 
savings of up to £20 million a year, 
and that fears they would lead to 
"large numbers" of pharmacies 
closing had "proven unfounded". 

The reforms had led to quantifiable 
annual savings to consumers of up 
to £33m and additional benefits of 
between £21m and £68m a year, 
the evaluation estimated. 

There had been increased costs to 
businesses and the NHS due to 
contract applications and appeals, 
the evaluation found, but the 
quantifiable net benefit was still 
between £12m and £20m. 

Since the reforms, there had been 
a 9 per cent increase in the number 
of pharmacies in England, the report 
said. And it found the rate at which 
pharmacies had closed since 2005 
was not greater than previously. 
"This evidence implies that 
pharmacies entering the market as 
a result of the 2005 reforms have 
not so far displaced existing 
pharmacies to any significant 
degree," the report concluded. 

Contractors split over 100 -hours 

Contractors delivered a mixed 
response to an evaluation that found 
control of entry relaxation had not 
forced out existing contractors. 

PSNC chief executive Sue Sharpe 
said England's contract negotiator 
had not changed its stance against 
deregulation since four control of 
entry exemptions, including 100- 
hour pharmacies, came into effect in 
2005. Mrs Sharpe has previously said 
market entry under the exemptions 
had diluted pharmacy funding. 

Both the Co-operative Pharmacy 
and Numark said that a lack of 
pharmacy closures was not proof the 
exemptions had not adversely 
affected existing businesses. "The 
fact that people haven't actually 

gone out of business isn't a case for 
stating that it hasn't had a negative 
impact," Co-operative Pharmacy MD 
John Nuttall said. 

But Asda superintendent John 
Evans and independent contractor 
Stephen Foster welcomed the 
findings of the independent 
evaluation of the 2005 reforms, 
carried out for the Office of Fair 
Trading. "Yet again, pharmacy has 
cried wolf, but in reality there hasn't 

been a negative impact," Mr Evans 
said. "What we need to do now is 
focus on giving our customers the 
best service possible; if [pharmacies] 
do that, they'll survive." 

And Mr Foster, of Pierremont 
Pharmacy in Broadstairs, Kent, 
agreed: "If there was no control of 
entry, I think those that were good 
would survive and those that 
weren't wouldn't - and I'm fully 
supportive of that." JR 

0»D &THE PDA@union 

Last chance to win an iPod 

Shuffle in our Salary Survey I Salary Survey 2010 

NCSO endorsements 

The DH and National Assembly 
for Wales have agreed to allow 
NCSO endorsements for the 
following items for March 
prescriptions: sulfinpyrazone 
100mg and 200mg tablets. 

PSNC charter 

PSNC has launched a community 
pharmacy charter campaign to 
help the sector engage with 
prospective parliamentary 
candidates in the run up to the 
general election. The charter can 
be used as a tool to promote the 
sector and push forward white 
paper reforms, PSNC said. 

Wales funds drugs pilot 

The Welsh Assembly Government 
has approved funding for a 
medicines management pilot to 
improve communications 
between primary and secondary 
care, especially when patients are 
discharged from hospital. 

Minor ailments call 

Pharmacy bodies have renewed 
calls for minor ailments services 
following a landmark paper from 
leading GPs. The CCA, PSNC and 
Community Pharmacy Wales 
backed the paper from the Self 
Care Campaign. 

NSAID launch 

Manufacturer Wockhardt has 
launched two new NSAID 
products. Both ibuprofen 200mg 
tablets (P) and ketoprofen 2.5 per 
cent w/w gel (POM) will be 
available from this month. 

300th Tesco pharmacy 

Tesco Pharmacy has opened its 
300th pharmacy, describing it as an 
"important step" in its expansion 
programme. Tesco now employs 
over 600 pharmacists and nearly 
3,000 dispensing technicians, 
dispensers and assistants. 

Patient safety 

More than 50,000 medication 
errors occurred across the NHS 
last year, according to a report by 
the NPSA. The figure makes up 10 
per cent of the total number of 
patient safety incidents reported 
to the organisation between April 
1 and September 30, 2009. 5 

See the full verdict on GPhC standards 


Nice bypass 

Innovative drugs for patients with 
rarer conditions will be able to 
bypass Nice appraisal under a 
three-year "innovation pass" pilot 
scheme, health minister Mike 
O'Brien has announced. The 
scheme means drugs for patients 
with rare conditions not appraised 
by Nice can be considered for use 
in the NHS. 

Stroke predictor 

Variation in systolic blood 
pressure measurements is a strong 
predictor of stroke in patients with 
a previous transient ischaemic 
attack (TIA), an analysis in The 
Lancet has found. The analysis 
found patients with a greater 
variability in blood pressure had a 
greater risk of subsequent stroke, 
independent of average systolic 
blood pressure. 

£30tQ)ik funxdiong 

The Pharmacy Practice Research 
Trust has offered £300,000 
funding for research projects 
investigating the effectiveness of 
pharmacy interventions in public 
health, managing long-term 
conditions, and treating minor 

Teva buys atiopharm 

Generics manufacturer Teva will 
buy Ratiopharm for £3.625 billion, 
the company has announced. The 
move, subject to regulatory 
approvals, is expected to be 
completed by the end of the year. 

RO> ,ip manifesto 

The Royal College of CPs has 
launched a manifesto outlining 
recommendations for the future 
of patient care. The college called 
for longer consultation times and 
GP training, and said GPs should 
work as part of enhanced primary 
care teams alongside pharmacists 
and other professionals. 

PSNC elections 

Three regional reps have been 
elected to PSNC: Elizabeth 
Hopkins will represent the London 
North Thames area, Indrajit Patel 
the London South Thames area 
and Gary Warner South Central. 

Conscience clause gets 
green light from GPhC 

But heavy criticism forces new regulator to revise standards proposals 

Max Cosney 

Pharmacists have been given the go- 
ahead to refuse to provide services 
that clash with their religious views 
by the new pharmacy regulator 

The pledge came as the General 
Pharmaceutical Council (GPhC) 
revealed it will continue with the 
existing code of ethics when it 
launches, following heavy criticism 
of a consultation on revised 

The conscience clause - which 
allows pharmacists to opt out of 
services such as EHC - will form part 
of the code, the GPhC said. However, 
exercising the powers could become 
subject to conditions including: 

Displaying notices telling patients 
about pharmacy services that could 
be refused on religious grounds. 

Clear guidelines on where it is 
acceptable for pharmacists to 
signpost patients to another 
provider when refusing supply. 

GPhC chair Bob Nicholls told 
C+D: "The steer for the council is to 
include the clause with guidance and 
draw attention to that guidance." 

The comments follow intense 
media criticism of the conscience 
clause earlier this month. 

A Lloydspharmacy pharmacist 
was vilified in several national 
newspapers for refusing to 

Pharmacists can go on refusing services like dispensing the Pill on religious grounds 

dispense the contraceptive Pill. 

Lloydspharmacy has launched an 
investigation into the incident and 
warned of conflicting guidance 
between NHS contracts and the 
code of ethics. 

The conscience clause was backed 
by over two thirds of respondents to 
a consultation on GPhC standards 
published this week. 

However, the document also 
noted the unpopularity of powers 
among patients. 

A final ruling on the conscience 
clause will form part of a broader 
review of standards by the GPhC 
later this year. 

The organisation found 
"considerable uncertainty and 
discontent" with standards put out 
to consultation last October. 

Respondents hit out at 
"inconsistent" and "ambiguous" 

The GPhC has been told to 
address these criticisms by 
overarching NHS regulator CHRE. 

"Poorly conceived and 
badly written" 

Staff shaken by knife 
and crowbar raider 

West London pharmacists are 
recovering from a nine-day crime 
spree that saw five pharmacies 
robbed and staff threatened with a 
series of deadly weapons. 

The robber struck at Courts 
Pharmacy, West Molesey, Surrey, on 
Wednesday March 3, threatening 
staff with a knife and demanding 
cash from the till. The thief also 
demanded drugs but the pharmacist 
refused to hand them over, leaving 
the robber to flee with £270. 

KC Pharmacy inTeddington, 
Middlesex, was targeted the next 
day, with the robber wielding a 

crowbar as he threatened to murder 
a member of staff if the pharmacist 
did not meet his demands. The 
robber demanded money and 
diazepam, before fleeing. 

Pharmacist Neetesh Gandhi told 
C+D he still felt shocked about the 
incident. "I chased him with two 
spatulas... and took his registration." 

Pharmacies in Esher, Weybridge 
and Claygate were also targeted 
between February 27 and March 6. 

Surrey police confirmed a man 
had been charged with three 
robberies and had been remanded 
in custody. CC 

See analysis of GPhC 
standards on plO 

Scots launch 
heart MOTs 

Community pharmacists could help 
roll out Scotland's planned 
cardiovascular screening 
programme, and an increased 
alcohol reduction service, the 
contract negotiator has said. 

The Scottish Government (SG) 
this week announced that work on a 
'heart MOT' for all 40 to 74-year- 
olds will begin in the autumn, with 
the first patients scheduled to 
receive the service in 2011. 

It has yet to decide how and by 
whom the service would be run. 
Community Pharmacy Scotland 
(CPS) will discuss pharmacy's role 
with the SG following cardiovascular 
screening pilots. JR 


H. **** 



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Community pharmacist wanted in Cambridgeshire 


Will you pay £192 
to join the new 
fessional body? 

"Yes, I would pay, 
and I don't feel it's 
too expensive. But 
I do believe we 
should consider 
the fact that the 
fee might be too 
expensive for 
newly qualified, 
part-time and retired pharmacists." 
Ceri Evans, Rowlands Pharmacy, 
Kettlethorpe, Wakefield 

"I will pay the 
£192, but I do 
think it's too 
expensive. It's 
difficult to say at 
HP this stage how 
much benefit we'l 
get. So I'll pay up 
front and then 
assess whether it's worth it." 
Chris Hollebon, Market 
Pharmacy, Shirebrook 

Web verdict 

Yes, it's worth it ■ 

Yes, but it's too expensive 29% 

No, my company is paying ■ 


A. •:■ The biggest January 

sale of 2011 could be at 1 Lambeth 
High Street, based on poll results. 
The organisation will have to do 
something to fill the coffers if only 
four in 10 pay up to join the PLB. 
Next week s question: 
Have the control of entry 
exemptions meant better quality 
pharmacy services for patients? 
Vote at 

Longer hours for nine 
out of 10 pharmacists 

Avicenna survey finds staff bogged down in red tape and paperwork 

Chris Chapman 

Pharmacists are working longer 
hours and are too tied up in 
paperwork and red tape to develop 
new services, a survey of 
independent contractors has found. 

The poll of 150 independent 
pharmacists by Avicenna found 95 
per cent of respondents were forced 
to work extra hours compared with 
last year. Over 80 per cent named 
admin burden as a major issue. 

And the problems were having a 
knock-on effect on services, the 
survey found. Over 70 per cent of 
respondents blamed lack of time and 
69 per cent red tape as factors 
preventing developments. 

Other concerns highlighted by the 
survey included 63 per cent of 
pharmacists feeling stressed, down 
13 per cent on last year, and 71 per 
cent worried about NHS funding. 

One area of concern was the 

devolution of greater powers to PCTs. 
Nine out of 10 respondents didn't 
know how pharmaceutical needs 
assessments would affect them. 

Speaking exclusively to C+D, 
Avicenna CEO Salim Jetha said stress 
in the sector was running "very 
high", with pharmacists forced to 
complete a "top heavy" amount of 
paperwork and insufficient funding. 
Policy makers did not consider the 
implications of their actions on 
pharmacist workloads, he added. 

"The outcome of this is reduction 
in staff, injecting more borrowed 
capital into the business. . . and 
resorting to desperate measures 
such as price checks." 

The survey also revealed a high 
level of dissatisfaction with 
pharmacy bodies, with 85 per cent 
rating the RPSCB's performance 
as poor, and 59 per cent unhappy 
with PSNC. However, 62 per cent 
said they still planned to join the 
professional leadership body. 

Scrap tax rises to boost 
employment, experts say 

Plans to increase taxes on small 
businesses should be scrapped to 
enable them to employ more staff, 
a leading lobby group has said. 

The warning came as sector 
analysts also warned some 
pharmacies could be caught out 
by new rules on filing VAT returns 
this April. 

The Forum of Private Business 
(FPB) said the tax rate rethink was 
needed to enable small businesses 
to lead the country out of recession. 
Matthew Goodman, the FPB's policy 
representative, said the forum 
believed this goal was "entirely 
realistic" and that helping small 
businesses to employ more people 
would lead to increased tax income 

for the government in the long term. 

Meanwhile others expressed 
concerns about changes next 
month, which will mean businesses 
turning over more than £100,000 
will have to file their VAT returns 
online. And from May they could be 
subject to new penalties for late 
payment of PAYE. 

Umesh Modi, a specialist 
pharmacy financial advisor at Silver 
Levene, said: "This will of course 
increase the administrative burden 
to get papers filed online and on 
time, or face interest and penalty 
charges for late filing." He warned 
that some pharmacies would 
"certainly find life difficult going 
forward". ZS 

Avicenna survey 
by numbers 


burdened by too much 


affected by stress at work 


stopped developing services 
because of lack of time 

Tell us about your 
working life 


for PLB fee 

Pharmacists can save up to £84 a 
year on their professional leadership 
body (PLB) fee through tax breaks, 
the RPSCB has announced. 

The savings follow negotiations 
with HM Revenue & Customs and 
mean the membership fee could be 
reduced to around £9 per month. 

However, only pharmacists 
earning more than £43,875 a year 
with a standard tax code can take 
advantage of the highest savings. 
Pharmacists with a standard tax 
code earning less than £43,875 
will save around £36 per year, 
reducing the membership fee to 
£13 a month. 

The £192 PLB membership fee will 
apply for those joining in 2011. CC 

Hurry! Survey closes March 31 

Fill in our Salary Survey and you could win an iPod Shuffle 

&the PDA©union 

strength in numbers 

Salary Survey 2010 


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Jibed at hKjh doses for prolonged penods Very common: epistaxis Epistaxis was generally mild to 
moderate, vwth incidences in adults and adolescents higher in longer-term use (more than 6 weeks). Common: 
nasal ulceration Rare, hypersensrrjvrry reactions including anaphylaxis, angioedema. rash, and urticaria. 
Precautions: Treatment with higher than recommended doses of nasal corticosteroids may result in clinically 
significant adrenal suppression. Consider additional systemic corticosteroid cover dunng penods of stress oi 
elective surgery Caution when prescribing concurrently with other corticosteroids. Growth retardation has been 
reported in children receiving some nasal corticosteroids at licensed doses. Monitor height of children. 
Consider referring lo a paediatnc specialist. May cause imtatjon of the nasal mucosa. Caution when treating 
patients with severe liver disease, systemic exposure likely to be increased Nasal and inhaled corticosteroids 
may result in the development of glaucoma and'or cataracts Close monitoring s warranted in patients with . 
ge in vision or with a history of increased intraocular pressure, glaucoma and'or cataracts Pregnancy 

and Lactation: No adequate data available. Recommended nasal doses result in minimal systemic exposure 
II is unknown if fluticasone furoate nasal spray is exacted in breast mlk. Only use if the expected benefits lo 
the mother outweigh the possible nsks to the foetus or child Drug interactions: Canton is recommended 
when co-administenng with inhibitors of the cytochrome P450 3A4 system, eg ketoconazole and ritonavir 
Presentation and Basic NHS cost: Avamys Nasal Spray Suspension 120 sprays: £6,44 Marketing 
Authorisation Number: EU/1/07/434/003 Legal category: POM PL holder: Glaxo Group Ltd, Greenford, 
Middlesex, UB6 ONN, United Kingdom Last date of revision: January 2010 

Adverse events should be reported. Reporting forms and information can be found at Adverse events should also be reported to GlaxoSmithKline 
on 0800 221 441. 

Avamys' is; 


trademark of the GlaxoSmrtfiKline group of companies. 

sensitized to mountain cedar pollen Curr Med Res Opin 2009. 25(6) 1393-1401 

4 Vasar M, Houle P Douglass J el al Fluticasone furoate nasal spray effective monotherapy for 
symptoms of perennial allergic rhinitis in adults/adolescents. Afagy Asthma Proc 2008, 29. 31 3-321 

5 Avamys Summary of Product Charactensto 2010. 

6. Berger WE, Godfrey JW, Slater AL Intranasal corticosteroids the development of a drug delivery 
device for fluticasone furoate as a potential step toward improved compliance. Expert Opin Drug Deltu 
2007, 4(6): 689-701. 

7. Berger W, Godfrey JW, Grant AC ef al Fluticasone furoate (FF) nasal spray - development ol a 
next-generaton delivery system for allergic rhinitis J Allergy Clin Immunol 2007: 119(1 Suppl): S231. 

8 Godfrey JW, Grant AC, Slater AL Fluticasone furoate (FF) nasal spray - ergonomic considerations 
for a next generation delwry system J Allergy Clin Immunol 2007, 119(1 Suppl): $230. 

© GlaxoSmMlme group of companies 2010 

Code UKIFFI0008/10 Date of preparation February 2010 

a 3. 

Fokkens WJ, Jogi R, Reinartz S el al. Once daily fluticasone furoate nasal spray is effective in 
seasonal allergic rhinitis caused by grass pollen Allergy 2007; 62 1078-1084 
Kaiser HB, Nacleno RM, Given J el al Fluticasone furoate nasal spray a single treatment option for 
the symptoms of seasonal allergic rhinitis J Allergy Clin Immunol 2007, 119(6). 1430-1437. 
Jacobs R. Martin B. Hampel F el al Effectiveness of fluticasone furoate 1 10pg once daily in the 
treatment of nasal and ocular symptoms of seasonal allergic rhinitis in adults and adolescents 

Allen s-Hamjufts 


Fieephon-i 0800 221441 
F9i 020 6990 4128 

* Cla»oSmitnK h 


Hostile verdict on CPhC standards 

Pharmacy's new regulator has been left with much to consider from the consultation on 
future standards. Max Gosney examines why the proposals proved so unpopular 

See the consultation feedback in full 

Back to the dra^dngjK)a^-4ive problems pharmacists found 

The documents are written in an 
inconsistent style and are too long, 
prescriptive and repetitive 

Why are standards being revamped 
so soon after the existing Code of 
Ethics was rewritten? 

The standards place too great an 
emphasis on pharmacists working in 
public-facing roles 

Wording is ambiguous and unclear 

^™ There is not enough evidence to 
support proposed changes in policy 

Source: CPhC standards consultation 

Whoever orders the stationery at 
the General Pharmaceutical Council 
(GPhC) might want to check the 
new office has a drawing board. 
The organisation was sent firmly 
back to it this week after the 
publication of responses to its 
consultation on standards for 
future pharmacy practice. 

Over 200 respondents, largely 
individual pharmacists, chastised the 
proposals as poorly conceived and 
badly written. The consultation had 
hoped to establish the holy grail of a 
new gold standard in pharmacy 
practice, but seems to have delivered 
a poisoned chalice instead. Central 
to many objections are two key 
areas: whether P medicines should 
be available for self-selection and 
the rights of pharmacists to refuse to 
supply prescriptions because of 
religious objections. 

In fact, so great was the strength 
of feeling that some respondents 
dedicated their entire feedback to 
the topics alone. The majority, nearly 
60 per cent, wanted a ban on self- 
selection of P medicines. But, you 
have to look beneath the headline 
figures to get a true sense of 
grassroots opinion. 

"The statistics do not bear out the 
general flavour of the comments 
provided," says overarching NHS 
regulator and consultation host 
CHRE. "Those who did comment 
were generally opposed strongly, 
on the grounds of pharmacy 
medicines' greater potential to 
cause harm." 

Specific safeguards must be drawn 
up by the GPhC to help diffuse the 
risk, pharmacists said. It's an idea 
being backed by CHRE, which has 
called on the new regulator to set 
out the safety measures to 
accompany self-selection. But 
despite this caveat, the door to 
self-selection is left open by the 
consultation. CHRE advises the 
GPhC that it is free to proceed with 
the concept despite noting 
wholesale opposition from patients 
and pharmacists. 

The pharmacy and the public 
view may have chimed on P 
medicines, but other topics proved 
more divisive. The conscience clause, 
which allows pharmacists to refuse 
to supply services on religious 

"fVfogii appear 
with what's on 
the table" 

grounds, was particularly contentious. 
Sixty seven per cent of respondents 
backed the clause, claiming that it 
would be discriminatory to force 
pharmacists into overriding religious 
views. Support was conditional 
though, with pharmacists having to 
direct patients to other services 
when exercising their right. 

However, CHRE noted a 
"compelling" argument against the 
conscience clause. For objectors 
the public interest eclipsed a 
pharmacist's right to a religious 
standpoint. Redirecting patients to 
alternative providers was also 
unsatisfactory, critics claimed, as 
many may not be able to summon 
the courage to ask two different 
people for a service. The opposition 
expressed in the consultation was 
reinforced by additional research 
showing unpopularity for the 
conscience clause among the public. 

CHRE's conclusion is that the 
powers should remain, with 
conditions. One of these will be a 

requirement to direct patients to 
alternative providers. Another urges 
pharmacy owners to display public 
notices letting patients know before 
they reach the dispensary if staff 
have religious objections to 
supplying their prescription. 

Reflecting these recommendations 
in a revised code of ethics must now 
be a priority for the GPhC. The 
regulatory team has much to 
consider, with CHRE also urging the 
organisation to take on board more 
general criticisms (see box above). 

So just weeks before pharmacy's 
new regulator is set to launch, it 
finds itself without a code of ethics. 
Yet the GPhC says it is not to blame 
for the delay. "We weren't even 
there when the research into the 
standards consultation was going 
on," says GPhC chair Bob Nicholls. 

Mr Nicholls points out that the 
GPhC was not a legal entity when 
the consultation launched last 
October. Instead, much of the 
groundwork was done by existing 
pharmacy regulator, the RPSGB 
and included workshops with 

"Having done that, it's a slight 
surprise that the negative views were 
so consistent and so strong," Mr 
Nicholls adds. 

But perhaps that strength of 
feeling is no bad thing, suggests 

Duncan Rudkin, GPhC chief 
executive. "It depends what you 
think the point of a consultation is," 
he says. "If you think it's to get your 
plans rubber stamped then that's 
not happened. But here the objective 
was to flush out views and to get 
people to air them." 

The GPhC certainly achieved that, 
with pre-consultation publicity 
calling for grassroots pharmacists to 
have their say really paying off. The 
response rate of 214 is on a par with 
feedback on 2008's landmark 
pharmacy white paper. 

The dilemma for the GPhC is that 
most appear disenchanted with 
what's on the table. An organisation 
meant to mark a clean slate for 
pharmacy regulation will now start 
life with the RPSGB's old code of 
ethics. Another consultation will be 
launched this April as the GPhC 
looks to get its standards sorted. But 
implementing the proposals could 
take until late summer. 

On the one hand the delay 
indicates a regulator that's 
prepared to listen and show 
flexibility - a buzzword of the GPhC. 
But there's only so much room for 
positive spin. It's far from ideal that a 
regulator first mooted in 2007 will 
launch without its own code of 
ethics - whoever is to blame for 
the hold up. 




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The sums are simple 
The more you spend the more 
you save. And the discounts 
start from the very First pound 
That's how to buy generics. 


Check out what's on TV this week 

Market focus 

• The total condom market is 
worth £51 million, with 
around £20m of sales in 
pharmacy (IRI Feb 2010). 

• Sensitivity is the largest 
condom sub-category and 
Durex condoms in this sector 
grew by 1.8 per cent last year 
to £ 15.5m (IRI Oct 3, 2009). 

Back Pain 

Kobayashi Healthcare will extend its 
Cura-Heat range with a larger back 
pain heat 
pack in 

Heat Back 
Pain Max 
Size is 
double the 
size of the 
back pain 
which makes it more suitable for 
those who suffer from severe 
back pain. 

Designed to be thin and discreet, 
the heat pack is claimed to offer 
soothing heat for up to 12 hours. 

The Cura-Heat range will be 
supported by a TV advertising 
campaign from the end of 2010 until 
winter 2011. 

Price and Pip code: £4.49/2 heat 
packs, 339-9763 
Kobayashi Healthcare Europe 
Tel: 0208 987 9967 

Durex in triple launch 

Retail talk 

Are customers 
confused about the 
difference between 
homeopathic and 
herbal products? 

Yes 33% 

Off the shelf view: 

A fairly unanimous verdict this 

week, highlighting pharmacists' 

uphill battle when explaining 

about herbal and homeopathic 


This week's question: 
Do you agree with changes to the 
advertising code that will allow 
condoms to be advertised on TV 
before the 9pm watershed from 
September? Vote at 

SSL International is launching 
three Durex condoms into the 
sensitivity category (see 
interview opposite). Durex 
RealFeel, Durex Fetherlite 
Ultra and Durex Deluxe have 
all been developed to offer 
improved sensitivity. 

Durex RealFeel is a non- 
latex polyisoprene condom 
that allows for effective heat 
transfer and provides a 'skin-on-skin 
sensation', says SSL. It has an easy- 
on shape for comfort and ease of use 

Durex Featherlite Ultra is the 
thinnest latex condom in the Durex 
range and is about the thickness of a 
human hair. It incorporates Sensi-fit 
technology to provide a closer 
feeling at the tip of the penis. 





Durex Deluxe is a premium 
condom (rrp £9.99/5), which will 
initially be exclusive to Boots stores. 
Made from clear micro-fine 
polyurethane, it is the thinnest 
condom to be introduced into the 
Durex range and is designed to 
improve body heat transfer between 
partners. This condom is packaged in 

Once-daily OA treatment 

BioPlus Life Sciences has launched 
licensed glucosamine sulphate 
1,500mg once-daily 

Dolenio glucosamine 
sulphate 1,500mg is 
indicated for the 
symptomatic treatment 
of mild to moderate 
osteoarthritis (OA) of 
the knee. 

The prescription-only 
treatment has been 
formulated to alleviate 
pain and joint stiffness, 
facilitate cartilage 
repair and improve patient mobility 
The once-daily dose may enhance 
compliance in patients who take 
several daily medications. 

BioPlus says Dolenio provides a 
new treatment option for OA 
patients who have previously been 


Glucosamine sulphate 

prescribed NSAIDS, which Nice does 
not recommended for long-term use. 

The company plans 
to release educational 
material for GPs and 
pharmacists to promote 
awareness. An 
accredited training 
module will be 
developed for 
pharmacists. The launch 
will be supported by a 
£500,000 campaign in 
the lead up to Arthritis 
Awareness Week in 
Dolenio is distributed in the UK by 
Alissa Healthcare. 

Trade price and Pip code: 
£18.20/30, 354-2099 
Alissa Healthcare 
Tel: 01489 780759 

Rescue Cream wins award 

Nelsons received double 
recognition for two 
different brand sponsorship 
programmes at the recent 
Hollis Sponsorship Awards. 

Rescue Cream won the 
First Time Sponsor Award 
for sponsoring Alternative 
Fashion Week and Spatone 
was highly commended in 
the Best Low Budget (under 
£50,000) Sponsorship category for 
sponsoring UK Olympic hopeful Lisa 

Pictured are Amy Fell, Nelsons 
communications executive (left) and 
Melaney Noon, Nelsons 

communications manager, receiving 
the First Time Sponsor Award from 
BBC sports presenter Garry 

a 'butter dish' case that ensures the 
condom is the right way up so it can 
be put on quickly and easily. 

Prices and Pip codes: RealFeel/10 
£9.95, 352-7223 Fetherlite 
Ultra/12 £9.95, 352-7231 
SSL International 
Tel: 0161 638 2000 

Nivea sun fun 
is child's play 

Beiersdorf has added two new 
products to its Nivea Sun range for 
this summer. Nivea Sun Kids Swim 
and Play SPF 30 and 50 protection 
lotion is formulated to provide long- 
lasting water resistance for children. 
For - 

Bronze is 
to help 
support the 
body's own 

production. The product comes in 
SPF10.20, 30 and 50. 

New packaging has also been 
introduced for the suncare range, 
which is being backed by a £1 million 
support programme. 

A 'Buddy up for Funshine' 
campaign, which features the 
brand's Sunwise Set characters, has 
been launched in primary schools to 
help children learn to stay safe in the 
sun. The teaching material has a 
sports emphasis, assembly plans and 
free products to help teachers 
communicate the importance of 
having fun but staying safe in the 
sun. A competition will offer schools 
the chance to win a personal visit by 
the Sunwise Set. 


Tel: 0800 289 515 

Prices and Pip codes: see C+D 
Monthly Pricelist or 
Beiersdorf UK 
Tel: 0121 329 8800 


Z 7.03.10 

Martyn Ward, Northern Europe regional MD and UK MD, SSL International 

New opportunity to boost condom sales 

EXCLUSIVE As SSL International launches its thinnest ever Durex condoms, Martyn 
Ward (right) explains how pharmacy can benefit from the sensitivity category 

Is there consumer demand 
for condoms that provide 
more feeling and sensitivity? 

A Through consumer research, 
we know that feeling ranks 
only behind safety in importance for 
our condom users. So it made sense 
for us to look at our offering within 
the feeling and sensitivity area and 
see how we could offer a greater 
choice of products. We have used 
different materials and thicknesses 
to allow consumers to cross- 
purchase and find which products 
are right for them. 

Does this category offer a 
retail opportunity for 
community pharmacies? 


Absolutely Feeling and 
sensitivity are important to 

consumers and our research shows 
that lack of sensitivity is often a 
reason for not using a condom. We 
expect two things to happen from 
this launch. As we increase the 
opportunity for consumers to buy 
into the sensitivity area, we expect 
to get some people who are not 
currently condom users to buy into 
this market We would also expect 
some trading between other 
categories to try new products. 

What plans do you have to 
develop this category in 
community pharmacy? 

A Our sales force will be going 
out to pharmacies armed with 
training and point-of-sale materials 
and we will be supporting the 
pharmacist in terms of knowledge 
about these products. We think that 

pharmacists and their staff are an 
underutilised resource. They have 
got a raft of skills that can really 
benefit the messages relating to 
sexual health 

How can pharmacies 
help overcome the 

embarrassment factor when 

discussing sensitivity? 

Sex is always a difficult 
subject and I think to walk 
up to someone who is standing by 
the condom fixture and say "can I 
help you sir?" is a step too far. But 
there are numerous conversations 
that go on in the pharmacy 
environment that can transfer 
across into asking, "what form of 
contraception have you used?". If 
someone has tried condoms, it can 
lead into asking, "did you like 

them?" and, if not, "was it because 
of sensitivity 7 ". 

How will you be promoting 
the new condoms? 

^ We haven't made final 

decisions about advertising 
yet. Now that the ASA [Advertising 
Standards Authority] has ruled that 
condom advertising can be shown 
on TV before the 9pm watershed 
from September 1, we are 
considering what that means for 
Durex. We will be very responsible 
about what messages we're 
delivering to whom and when. With 
the pregnancy and STI rates that we 
have in the UK, there is clearly a 
need for sensible, well-targeted 
messages and we think removing 
the watershed is good news for the 
sexual health of the nation. 


The business of pharmacy 
is changing all the time 
Stay in the know with 
the Actavis Academy, 
A discount scheme with 
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What do you think? 

|= ' ; :!< 

nt membership value for our money 


You can't get much for four quid a week these 
days. It costs me double that for a daily paper, so 
PLB membership for just £192 should sound great 
value. Indeed, the glossy new website lists five 
areas of benefit, all for less than £4 a week - that's 
less than 80p a benefit. If I'd realised I could get 
leadership for less than 80p a week, I'd have 
started paying years ago... 

The trouble is, the more I thought about 
"Support, Development, Recognition, Network 
and Leadership", the harder it was to see what I 
don't have already. I understand how some are 
confusing it with a trade body or a union with the 
NPA strapline being "Representing, Supporting 
and Protecting", and the PDA also offering support 
and protection, and there are so many offers of 
CPD from a host of providers in addition to CPPE 
that I'm starting to feel over-developed. 

So we're left with Recognition, Networking 
and Leadership. For £4 a week - that's now £1.30 
a benefit, and starting to look expensive, as 
"Recognition" means a badge that says 
MRPharmS, and the "Networking" mix of local 
forums and online groups sounds like a CPPE event 
followed by an hour on Facebook. 

So what do I need? If I were to do a 
pharmaceutical needs assessment (PNA), then 
high on the list would be things out of my personal 
control. I want to feel my profession is nationally 

respected. I want to know that my pharmacy NHS 
business is secure enough that I can invest money 
in developing new services. I want to see quality 
rather than quantity remunerated. I want to be 
able to use my professional judgement, and be 
supported for doing so. And those are things that 
need "Leadership". 

Of course it's easy to mistake management for 
leadership. Management is about doing things 
right and getting things done, which we do need in 
pharmacy, because it would make a change to feel 
those in charge were getting it right and making a 
difference. Leadership, however, is about going 
somewhere. A leader has to give a vision of where 
we're going, a plan of how we're going to get there, 
and encouragement to overcome the barriers. 
That's what the PLB must do and, importantly for 
the 90 per cent in the C+D poll who don't think 
Nurse Helen was the right choice as our chief, it 
doesn't take a pharmacist to be a leader. 

Now, I'm about to have a competitor move into 
our local surgery, and times are going to be hard. 
Like many faced with new 100-hour or polyclinic 
contacts, I certainly need to be given a vision of 
where my pharmacy is going other than down the 
pan, because I'm not convinced the PCT's PNA will 
give me that. Such leadership would be worth the 
PLB fee alone - but it had better come quick, while 
I can still afford £4 a week! 

This is no time for complacency 

At last week's Community Pharmacy 
Conference, I was struck by how far 
our profession has come in the past 
10 years. A decade ago, would we 
have seen government and 
opposition health spokespeople 
joining our conference to slug it out 
with each other over the intricacies 
of pharmacy service development? 
Would they have entered the lions' 
den that is a Q&A session with a 
room full of pharmacists? I suspect 
not. Community pharmacy is at the 
heart of the health policy agenda in 
a way it has never been before. 

I recently wrote that while the 
parties' broad calls for an expanded 
role for pharmacy were reassuring, 
they were notably light on detail. I 
am pleased to say all three parties 
have since shown a willingness to 
back up rhetoric with practical policy 
commitments. Mike O'Brien's action 
(C+D, March 20, p6) to protect 
contractors' income demonstrates 
an acknowledgement of the 
importance of consistent funding 
and a recognition of pharmacies' 

willingness and ability to develop 
services. He has listened to PSNC 
and acted. Mark Simmonds MP, his 
Conservative shadow, set out some 
strong commitments too, not least a 
place as of right for pharmacy on 
PCT boards or relevant committees. 

That said, now is no time for 
complacency. With the NHS facing 
the most difficult financial era in its 
history, community pharmacy must 
not shy away from communicating 
its value. Community pharmacy 
must demonstrate that it can be 
instrumental in tackling the quality 
and productivity challenge. 

This is an argument we are well- 
placed to win. The CBI recently 
asserted that £4.8 billion could be 
saved by moving the 57 million 
minor ailments-related consultations 
GPs deal with every year into 
pharmacies. By supporting patients 
on complex courses of medication, 
pharmacists can help slash the 
£100m or more that medicine 
wastage costs the NHS. And by 
providing accessible services at the 

heart of the community, pharmacies 
can help cut the long-term cost to 
the NHS of smoking, obesity and 
sexually transmitted diseases. 

Our argument is strong. But this is 
a competitive landscape, so we must 
be proactive and robust in making it. 
Both government and the NHS must 
understand that a clear business 
case exists for investing in pharmacy. 
This is as important at a local level 
as it is in Whitehall and Westminster. 
This month, PSNC is supporting all 
LPCs in launching their own 
community pharmacy charter 
campaigns, based around shared 
goals for pharmacy service 
expansion. LPCs and contractors can 
use the charter to engage with local 
politicians, commissioners, patient 
groups, the media and the public. 

Together, whether it's PSNC at 
the centre or LPCs and contractors 
locally, let us make sure that the 
people who matter hear pharmacy's 
voice - loud and clear. 
Sue Sharpe is chief executive of 



treating value in pharmaceuticals 


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That's how to buy generics 

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One-stop accredited training for counter 
assistants and dispensing assistants at 
or phone 0207 921 8425. 



Update: managing 
patients on warfarin 

INR checking, spotting 
adverse reactions and 
giving lifestyle advice 

Practical Approach 

Prescribing for 
hypertension in a 
woman in her mid-40s 
who comes in for a 
routine medical 

Ethical Dilemma 

This month's scenario 
involves being asked 
to supply a POM pack 
of EHC off script. What 
would you do in this 

C ategory M 

Generic Eric has some 
good news on 
reimbursement rates 
for the second quarter 


Anna Creswell talks 
about her role as a 
network development 

A R X 

Issue 10 • 2010 


Automating Pharmacies 


Over a number of years ARX and Dollar 
Rae have forged a successful working 
relationship supplying pharmacies with 
award winning services throughout the UK. 
A prime example can be found when ARX 
and Dollar Rae teamed up to provide the 
Primary Care Pharmacy in Nuneaton with 
a ground-breaking automated system and 
pharmacy installation. The service 
provided helped to ensure owner Michael 
Burr received the coveted Independent 
Pharmacist of the Year award and the 
Pharmacy Business Entrepreneur of the 
Year award for his high level of service and 
business innovation. 

The first floor houses the robot installation 
along with some 90 per cent of the 
pharmacy's stock, a dispensary for 
residential care and nursing homes, an 
internet pharmacy service, and 
physiotherapy and chiropody treatment 
facilities. By introducing the robot and 
locating it on the first floor, the pharmacy 
has been able to save space in the new 
shop and cut patient waiting times for 
prescriptions. This has allowed it to 
provide two well-proportioned and well- 
appointed consultation rooms and 

introduce new retail categories such as its 
section for Healthy Living offering vitamins 
and supplements, sun creams, etc. It has 
also enabled staff to be re-deployed in 
clinical care activities and to devote more 
time to counselling and building 
relationships with patients. Moreover, Mr 
Burr said, 'the robot will allow the 
pharmacy to decrease the number of 
medication-related errors.' 
"It's very impressive," he added. "The 
customers think it is fantastic. It's a state- 
of-the-art refit from Dollar Rae for a 
pharmacy with a state-of-the-art 
dispensing robot from ARX." 
The ground floor caters for the pharmacy. 
Within that there is the Dispensary using 
only one counter to double up as a 
dispensing workbench and a medicines 
counter, two consultation rooms, a section 
for OTC medicines, a Healthy Living 
section, two Healthpoints, eight delivery 
chutes from the robot, and a waiting area. 
"By changing our pharmacy design to have 
only one counter instead of two there is a 
lot more interaction with the patients and a 
lot more potential to offer more services," 
explained Mr Burr. 

ressive Tandem 
bot in Prospect House Pharmacy. 

ition schedule 04 
Where to see the ARX team over the 

ig year. 

at ARX 
ory Woodroffe, 
lales Executive - Scotland 

el: +44(0)1727 790446 • Fax: +44(0)1727 893: 




2010 looks set to be another big year for 
ARX. Towards the end of 2009 ARX 
launched the next generation of pharmacy 
automation into the market, the Vmax. 
The most technologically advanced robot 
to date looks set to dominate the market 
in both the community and hospital 
sectors, while the new Topspeed 200 
brings automation to pharmacies looking 
to maximize limited space. In 2010 ARX 
aims to bring the option of automation to 

Late in 2009 ARX saw its market share 
topping 80%, cementing ARX as the 
number one choice for pharmacy 
automation across the UK. Our ability to 
offer bespoke systems, tailored to the 
exact needs and requirements of our 
customers, has helped introduce 
automation across a huge variety of 
pharmacies. Our aim is to benefit 
pharmacies in three main areas; time, 
space and control. Moving into 2010 with 
the new generation of robots, this is 
becoming a reality for a growing number 
of pharmacies. The Topspeed 200 is able 
to automate upwards of 75% of the 
pharmacy throughput. The Vmax takes 
automation to the next level, with the 
ability to automate 98% of a pharmacies 
throughput and pick up to 9 packs in any 
one movement, thus increasing speed 
and capacity. Key to many pharmacists is 
control over stock and dispensing errors. 

Cases such as Elizabeth Leigh being 
handed a suspended prison sentence, 
highlights the need for pharmacists and 
dispensers to use the most precise 
equipment available. Many pharmacists 
are looking to ARX to provide them with a 
system that signficantly reduces 
dispensing errors, thus protecting their 
pharmacy and staff against the possibility 
of prosecution. The introduction of robots 
into pharmacies has minimised picking 
errors, improving the levels of patient 
safety and safeguarding against 

A special congratulations also goes out to 
our Sales and Marketing Director David 
Harper on the birth of his first child Oliver 
David Montague Harper. 

mrm CMiarvi Chemists., 

Here at ARX we understand how important 
it is to have a professional and impartial 
shopfitting company capable, not only of 
incorporating automation into a new shop 
fit, but also able to offer impartial advice 
relating to automation. Dollar Rae has vast 
experience of incorporating automation 
projects throughout the UK. 
Dollar Rae played a key role in the 
installation of an ARX Select robot at the 
Primary Care Centre in Cleethorpes. 
The modern pharmacy forms part of the 
Cleethorpes Primary Care Centre which 
accommodates seven GP surgeries. 
The bold technological investment was 
made by husband and wife team, Terry 
and Ann Birmingham, who own and run the 

impressive and visually-appealing 
Birmingham Chemists, which has just been 
created at the health centre by the leading 
pharmacy design and development 
specialists Dollar Rae. 

"We are a very busy pharmacy," states Terry, 
"and that is one of the reasons we put the 
robot in. It gives us great scope to cope with 
a greater volume by dint of its capacity to 
store stock easily. If we had put ordinary 
shelving in we probably would have struggled 
for space. The robot itself probably does not 
save us that much in time, but it is economical 
in space. It also looks nice and tidy." 
Together with Dollar Rae, ARX can offer 
practical solutions to all pharmacies looking to 
introduce automation in to their business. 


10446 • Fax: +44(0)1727 893361 • Email: • Web: 

nationalgrid CARBON MONOXIDE KIL. 

Suspect CO poisoning? Turn applianc 

Open doors and windows. 
Get everyone outside into fresh air imm 

In a medical emergen 
don't delay: phone 91 www.gassafereg; 


/ GAS^ 




Olivia (2) 




what is carbon 

Carbon monoxide (CO) is a 
colourless, odourless, tasteless, 
poisonous gas which can be 
emitted by faulty appliances 
powered by any fuel that burns. 

how can I 
protect myself? 

Once a year, service all 
appliances powered by any fuel 
that burns: gas, coal, oil, petrol, 
wood etc. Sweep chimneys 
and flues. Landlords are legally 
bound to arrange 
annual gas safety checks and 
suppliers offer free yearly 
gas checks to some vulnerable 

can't I just fit 
an alarm? 

CO alarms are important but 
ARE NOT a substitute for 
servicing or annual safety 
checks. Audible CO alarms 
SHOULD comply with BS EN 
50291 and carry a 
British/European approval mark 

®9 ESSFfflffl 

who can work on 
my appliances? 

Services and checks must 
ALWAYS be carried out by 
registered installers. DO NOT 
USE an appliance unless 
you are certain it's been 
professionally installed. 

signs of carbon 

Look out for gas appliances 
burning with a yellow/orange 
flame that's normally blue, extra 
condensation, pilot 
lights blowing out, sooting 
and/or yellow stains round 

symptoms of 
carbon monoxide 

• 'flu-like' symptoms 

• breath lessness 

• chest or stomach pains 

• feeling tired or drowsy 

• erratic behaviour 

• giddiness/headaches 

• nausea and/or vomiting 

• visual problems 

Chronic health problems? 

Visit your GP or phone your NHS information service 

New Once Daily Mirapexin (pramipexole) 

Prolonged Release - For the treatment of Parkinson's Disease 

Dosing Guide - Simple to initiate and titrate 

One dose, once a day, right from the start 

Recommended titration schedule 1 

Prolonged Release Once Daily Immediate Release 

3 x Daily 


equivalent to 

Salt (mg o.d.) 

Equivalent to IR formulation- 


Q.26mg 0.375mg 

Base: 3 x 0.088mg 
Salt: 3 x 0.125mg 


0.52mg 0.75mg 

Base: 3 x 0.18mg 
Salt: 3 x 0.25mg 


)5mg 1.5mg 

Base: 3 x 0.35mg 
Salt: 3 x 0.5mg 

4 ;; 

1 .5 7mg 


Base: 3 x 0.53mg 
Salt: 3 x 0.75mg 




Base: 3 x 0.7mg 
Salt: 3 x LOOmg 




Base.- 3 x 0.88mg 
Salt: 3 x 1.25mg 


3.15mg 4.5mg 

Base: 3 x 1.05mg 
Salt: 3 x 1.5mg 

Increase by 0.75mg (salt)/day each week, up to 4.5mg (salt)/day as required 

Inl.llrl'-, Mill ,11 I [ l.-l '.!/< 

Original Pack Identification Guide 



Mirapexir/ 0.26 mg 

30 prolonged-release tablets 

Once daily 

f£\ Boehnncer 
^lllr [ngelheim 

New Once daily 


prolonged release tablets 

A whole day in one dose 

Prescribing information appears overleaf 

Ordering information 

Mirapexin Prolonged Release 

Mirapexin IR 

Base Dose mg 

PIP Codes 



348 - 2882 


348 - 2890 


348 - 2908 


348 - 2916 

Base Dose mg 

DUD ftr\Aac 


0.18mg (30) 

258 - 6220 

0.18mg (100) 

258 - 6246 

0.35mg (30) 

334 - 2029 

0.35mg (100) 

334 - 2037 

0.7mg (30) 

258 - 6253 

0.7mg (100) 

I- ■ -■ ■ ■ - ■ — 

Prescribing Information UK 

Mirapexin' prolonged-release (pramipexole) 

Mirapexin 0.26mg, Mirapexin O.^mg, Mirapexin l.OSmg, Mirapexin 2-lmgand Mirapexin 3.15mg 
prolonged release tablets containing 0.375mg, 0.75mg, 1.5mg, 3mg and 4.5mg respectively of 
pramipexole dihydrochlonde monohydrate Indications: The treatment of the signs and symptoms 
of idiopathic Parkinson's disease (PD), alone (without levodopa) or in combinalion with levodopa. 
Dose and Administration: Adults only. Take each day at about the same time with or without 
food. 0.37Smg salt (0.26rng base) per day for first 5-7 days. Increase to 0.75mg salt (0.52mg 
base) in second week and l.Smg salt (l.OSmg base) in third week- If necessary increase daily 
dose by 75mg salt (0.52mg base) at weekly intervals up to a maximum of 4 5mg salt (3.15mg 
base). See SPC for more information on dose schedule. Abrupt discontinuation of dopaminergic 
therapy can lead to the development of neuroleptic malignant syndrome. Renal impairment: See 
SPC for revised dosage. Hepatic impairment: Dose adjustment in hepatic failure is not required. 
Contra-indications: Hypersensitivity to any constituent Warnings and Precautions: Inform 
patients that hallucinations (mostly visual) can occur. Somnolence and uncommonly, sudden 
sleep onset have been reported; patients who have experienced these must refrain from 
driving or operating machines Pathological gambling, increased libido and hypersexuality have 
been reported in patients treated with dopamine agonists for Parkinson's disease, including 
pramipexole Impulse control disorders such as binge eating and compulsive shopping can occur. 
Patients with psychotic disorders. Ophthalmologic monitoring is recommended at regular intervals 
or if vision abnormalities occur. In case of severe cardiovascular disease, care should be taken. It 
is recommended to monitor blood pressure, especially at the beginning of treatment, due to the 
general risk of postural hypotension If dyskinesias occur in combinalion with levodopa during 
initial titration of pramipexole in advanced Parkinson's disease, the dose of levodopa should be 
reduced. Interactions: Inhibitors of the cationic secretory transport system of the renal tubules 
such as cimetidme, amantadine and mexiletme may interact with pramipexole resulting in reduced 
clearance of either or both drugs. Consider reducing pramipexole dose when these drugs are 
administered concomitantly. The dosage of levodopa should be reduced, and other Parkinsonian 
medicinal products kept constant, while increasing the dosage of pramipexole. Caution with 
other sedating medication or alcohol due to possible additive effects. Coadministration of 
antipsychotic drugs with pramipexole should be avoided Pregnancy and Lactation: Effects 
of pramipexole in human pregnancy or lactation have not been studied. Pramipexole should 
not be used during breast-feeding. Undesirable Effects: Frequency of adverse reactions from 
placebo controlled clinical trials in Parkinson's disease includes; Very Common (al/10) - nausea, 
dizziness, dyskinesia, hypotension and somnolence. Common (al/100 to < 1/ 10) - insomnia, 
hallucinations, amnesia, behavioural symptoms of impulse control disorders and compulsions, 
restlessness, visual disturbance including vision blurred and visual acuity reduced, headache, 
latigue, constipation, vomiting, weight decrease, abnormal dreams, confusion and peripheral 
oedema Hypotension may occur at the beginning of treatment, especially if Mirapexin is titrated 
too fast. Especially at high doses seen in Parkinson's disease, signs of pathological gambling, 
increased libido and hypersexuality have been reported, generally reversible upon reduction of 
dose or treatment discontinuation. See SPCs for other undesirable effects. Pack sizes and NHS 
price: 30 tablets; 0.2bmg (0.375mg) £28.65; 0.S2mg (0.75mg) £57.30; 1.05mg (1.5mg) £114.60; 
2 ling (3mg) £229.20; 3. 15mg (4.5mg) £343.80 Legal Category: POM Marketing Authorisation 
Holder: Boehringer Ingelheim International GmbH, D-55216 Ingelheim am Rhein, Germany. 
MA Numbers: EU/1/97/OS1/014 (0.26mg (0.375mg)), EU/1/97/051/017 (0.52mg (0.75mg)l, 
EU/1/97/051/020 (l.OSmg (1.5mg)); EU/1/97/051/023 (2.1mg (3mgl); EU/1/97/051/026 
(3 15mg (4.5mg)). Prescribers should consult the Summary of Product Characteristics for full 
prescribing information. Prepared in October 2009 Further information is available from 
Boehringei Ingelheim Ltd.. Ellesfield Avenue, Bracknell. Berkshire RG12 8YS. 

Prescribing Information PD UK 
Mirapexin' (pramipexole) 

Mirapexin 0.088mg, Mirapexin 0. 18mg, Mirapexin 0.3 5mg and Mirapexin 0.7mg tablets containing 
0.125mg. 0.25mg, 0.5mg and l.Omg respectively of pramipexole dihydrochloride monohydrate. 
Indications. The treatment of the signs and symptoms of idiopathic Parkinson's disease (PD). 
alone (without levodopa) or in combination with levodopa. Dose and Administration: Adults 
only. Take equally divided doses three times per day with or without food. 3 x 0.12Smg salt (3 x 
0.088mg base) per day for first 5-7 days. Increase the daily dose by 0.75mg salt (0.54mg base) 
at 5-7 day intervals to a maximum dose of 4.5mg salt (3.3mg base) per day if necessary. See 
SPC for more information on dose schedule. Abrupt discontinuation of dopaminergic therapy 
can lead to the development of neuroleptic malignant syndrome. Renal impairment: See SPC for 
revised dosage. Hepatic impairment: Dose adjustment in hepatic failure is not required. Contra- 
indications: Hypersensitivity to any constituent Warnings and Precautions: Inform patients 
that hallucinations (mostly visual) can occur. Somnolence and uncommonly, sudden sleep onset 
have been reported, patients who have experienced these must refrain from driving or operating 
machines. Pathological gambling, increased libido and hypersexuality have been reported 
in patients treated with dopamine agonists for Parkinson's disease, including pramipexole. 
Impulse control disorders such as binge eating and compulsive shopping can occur. Patients 
with psychotic disorders. Ophthalmologic monitoring is recommended at regular intervals or if 
vision abnormalities occur. In case of severe cardiovascular disease, care should be taken. It is 
recommended to monitor blood pressure, especially at the beginning of treatment, due to the 
general risk of postural hypotension. If dyskinesias occur in combination with levodopa during 
initial titration of pramipexole in advanced Parkinson's disease, the dose of levodopa should be 
reduced Interactions: Inhibitors of the cationic secretory transport system of the renal tubules 
such as cirnet id ine, amantadine and mexiletine may interact with pramipexole resulting in reduced 
clearance of either or both drugs. Consider reducing pramipexole dose when these drugs are 
administered concomitantly. The dosage of levodopa should be reduced, and other Parkinsonian 
medicinal products kept constant, while increasing the dosage of pramipexole. Caution with 
other sedating medication or alcohol due to possible additive effects. Coadministration of 
antipsychotic drugs with pramipexole should be avoided. Pregnancy and Lactation: Effects 
of pramipexole in human pregnancy or lactation have not been studied. Pramipexole should 
not be used during breast-feeding. Undesirable Effects: Frequency of adverse reactions from 
placebo controlled clinical trials in Parkinson's disease includes, Very Common (>1/10) - nausea, 
dizziness, dyskinesia, hypotension and somnolence. Common (al/100 to <1/10) • insomnia, 
hallucinations, amnesia, behavioural symptoms of impulse control disorders and compulsions, 
restlessness, visual disturbance including vision blurred and visual acuity reduced, headache, 
fatigue, constipation, vomiting, weight decrease, abnormal dreams, confusion and peripheral 
oedema. Hypotension may occur at the beginning of treatment, especially if Mirapexin is 
titrated too fast. Especially at high doses seen in Parkinson's disease, signs of pathological 
gambling, increased libido and hypersexuality have been reported, generally reversible upon 
reduction of dose or treatment discontinuation. See SPCs for other undesirable effects. Pack 
sizes and NHS price: 30 tablets: O.OSSmg (0.125mg) £9.55; O.lSrng (0.25mg) £19.10; 0.35mg 
(0.5mg) £38.20; 0.7mg (l.Omg) £76.40, 100 tablets: 0.18mg (0.25mg) £63.67; 0.35mg (0.5mg) 
£127.34; 0.7mg (l.Omg) £254.69. Legal Category: POM. Marketing Authorisation Holder: 
Boehringer Ingelheim International GmbH, D- 552 16 Ingelheim am Rhein, Germany MA Numbers: 
EU/1/97/051/001 (30 tablets: 0,088mg (0.125mg)(, EU/1/97/051/003 (30 tablets: 0.18mg 
(0.25mg)) ; EU/1/97/051/004 (100 tablets: O.lSrng (0.25mg)l; EU/1/97/051/01 1 {30 tablets: 
0.35mg (0.5mg)); EU/1/97/051/012 (100 tablets: 35mg (0.5mg)) : EU/1/97/051/005 (30 
tablets: 0.7mg (l.Omg)); EU/1/97/051/006 (100 tablets: 0.7mg (l.Omg)). Prescribers should 
consult the Summary of Product Characteristics for full prescribing information. Prepared in 
October 2009. Further information is available from Boehringer Ingelheim Ltd., Ellesfield Avenue, 
Bracknell. Berkshire RG12 8YS. 

Adverse events should be reported. Reporting forms and information can be found at 
Adverse events should also be reported to Boehringer Ingelheim Drug Safety on 0800 328 1627 (freephone). 

References: 1 Mirapexin' Prolonged Release Tablets SPC, 2009 2 Mirapexin" Immediate Release Tablets SPC, 2009 

Date of preparation January 2010 

/jfj\ Boehringer 
villllli/ Ingelheim 

A R X 

Kettering Tandem Review 

We caught up with Graham Bell the Head 
Pharmacist at Prospect House in 
Kettering. Graham, who joined the 
pharmacy in July 2009, had not previously 
worked with an automated pharmacy 
system but has been a keen supporter of 
the concept for over 10 years. Now that 
Graham has had the chance to work 
directly with the state of the art Tandem 
Select robot system at Prospect House we 
asked him how the robot benefits both the 
pharmacy and most importantly their 

"Firstly I would not like to be without one, I 
have wanted one for 10 years after seeing 
an installation at the Northampton General 
Hospital. One of the robot's main 
strengths is the ability to cope with a 
sudden rush of customers and minimise 
waiting times for them." The pharmacy 
serves two surgeries with an average of 
15,000 scripts per month. Across a day 
the pharmacy dispenses, on average 1 
item per minute and during peak times can 
reach up to 10 items per minute. Coping 
with this, according to Graham, "...would 
not be possible with past dispensing 

"With the pharmacy serving two doctors' 
surgeries we tend to get customers in large 
bursts. The robot allows the pharmacy 
staff to deal with the queues quickly but 
most importantly, as the robot picks up the 
script and delivers it straight the 
pharmacist, they can spend more time 
with their customers. The whole work flow, 
from receiving the customer's script 
through to dispensing the order, is greatly 

improved in both speed and efficiency. 
Working with robots for the first time 
Graham praised the ARX team for their 
support in getting himself and his team up 
to speed. "In the first three months the 
ARX team were a great help. The service 
team were always on hand to deal with any 
issues, that are inevitable with the 
introduction of a brand new system and 
technology into a pharmacy. After three 
months, the team's knowledge was at a 
level were we could comfortably use all the 
features on the robot, further adding to the 
efficiency of the pharmacy. 
Apart from the speed and efficiency of the 
robot, Graham goes on to mention that the 
robot has been a success in more ways 
than one. "The kids love it. We have 
television screens showing the robot in 
action, picking and dispensing orders. 
This is always a cause of fascination for 
both children and adults, especially the 

The pharmacy has been trading for two 
years and over this period has seen a 
growth of 12 and 13 per cent respectively. 
With the robot's ability to streamline the 
pharmacy aspects of time, space and 
control along with its ability to 'wow' 
customers, another successful year is 
predicted for the pharmacy. 

isi IB* ) 

News roundup: 

ARX Launches Acculabel 

Helping reduce picking and labelling 
errors, the Acculabel links straight to 
existing PMR systems. Once the pack 
is scanned the correct label is printed. 
Using your current PMR system, 
process the prescription as normal, 
collect your pack and take them to the 
Acculabel. When the pack is scanned 
and recognised as part of that 
prescription, the label is printed. Final 
checks are performed and the 
customer's prescription is delivered. 

S.O.S. Healthcare in Ireland 
make double purchase. 

Fast expanding S.O.S. Healthcare are 
opening a new site in Limerick and have 
chosen ARX to solve their automation 
problems. The new site will be installed 
with a HD Medi JV 400 and also a 
Topspeed 200 machine. With 15 sites, 
and growing, we are extremely happy to 
be working with one of Ireland's premier 
pharmacy chains. 

Murrays purchase two Vmax 

With 25 stores nationwide we are 
delighted to announce that Murrays 
have taken the decision to install 2 
Vmax machines with optional Prolog 
and Store RX extras. We look 
forward to a long and successful 
relationship with the Murrys team. 

Gnosal pharmacy to fully 

Gnosal pharmacy, an independent store, 
based in Staffordshire, have purchased 
a Vmax, Prima and Acculabel. They are 
also looking to provide an option for out 
of hours service and are looking to ARX 
to provide the solution. 

ARX in numbers 

There are almost 3,000 ROWA systems 
across Europe of which over 350 are in 
the UK. ARX is delighted to have a 
market share of approximately 80%. 

Rory Woodroffe 
Sales Executive 


Rory Woodroffe is our new 
Community Sales Executive for the 
North. You wouldn't think so to speak 
to him but Rory was born in the 
Shetlands and considers himself a 
proud Scot. 

Rory came to ARX after gaining 
diverse experience in a number of 
sales and customer service roles. He 
is a qualified personal trainer and had 
a short spell in the Royal Marines 
before injury robbed him of a career. 
He is interested in anything that can 
potentially improve people's health. 

He is delighted to be selling products 
that cut out human error in dispensing 
and enable pharmacists more time to 
spend with patients. He is particularly 
looking forward to making Scotland 
as successful for ARX as England 
and Ireland in the coming years. 

ARX will be present at a variety of exhibitions across Europe. This is your 
opportunity to take a closer look at some of the latest equipment and to talk 
about your requirements with our experienced staff. 

24th - 26th March 2010 

EAHP Hospital show, Acropolis Convention Center 

27th - 29th March 2010 

Pharmagora, Porte de Versailles, Paris 

7th - 10th October 2010 

Expopharm, International Congress Center, Munich 

11th - 12th October 2010 

The Pharmacy Show, NEC Birmingham 

Call us now to discuss how 
A C !X amom^M >n ' ~in heff /oil: 

ARX Ltd 

Unit 6 Beaumont Works, 
Hedley Road, St Albans 
AL1 5LU 

Tel: +44(0)1727 790446 
Fax: +44(0)1727 893361 
Email: sales@arx 
Web: www.,arx=ltd. 

ARX International 

Belgium - Luxemburg 

Avenue Henri Jaspar 99 



La Petite Periche 

Route de Navrans 



CI Camino de Casabermeja, 
118, bajo 
29014 MALAGA 

Switzerland 5, Route de Chene 
case postale 6298 
CH-1211 GENEVE 6 


d by Luke Lowles-Hourigan • Designed by 

Browse C+D's Update archive for CPD help 

27.03.10 t' 


Your weekly CPD revision guide 

60-second \y 

Use this article as part of your CPD to 
update your knowledge of warfarin. 

What is the greatest risk 
with warfarin? 

Haemorrhage, which can occur in 
the normal therapeutic range. Signs 
include bleeding gums, nose bleeds, 
bruises under the skin, red or dark 
brown urine. 

What is the usual 
maintenance dose? 

Between 3mg and 9mg daily to achieve a 
target INR for atrial fibrillation of 2.5, give 
or take 0.5. 

Why should aspirin 
and warfarin not be 

There is no therapeutic benefit and 
bleeding risk increases. 

Why is infection relevant 
to INR? 

Vitamin K, involved in blood clotting, is 
synthesised by gut bacteria so anything 
affecting these bacteria, such as 
itibiotics, can affect the INR. 

s article (Module 1519) can help in the 
llowing CPD competencies: Gla, Glc, 

Supported by 

Managing patients 
on warfarin 

INR checking, spotting adverse reactions 
and giving lifestyle advice 

Rosemary Blackie MRPharmS 


Anticoagulation is frequently encountered in 
community pharmacy as there are several 
indications for its use. The main indication is DVT 
prevention, but it is also used in pulmonary 
embolism and to prevent clotting in people with 
mechanical heart valves. However, a key 
indication is for stroke prevention in those at risk 
of embolism from atrial fibrillation (AF), and this 
is the main focus of this article. 

Because of the chaotic blood flow in the heart, 
patients with AF are at five to six times greater 
risk of stroke than those in normal sinus rhythm, 1 
with the clot most often forming in the left side 
of the heart. 2 

Anticoagulation in AF 

Two classes of oral anticoagulants are currently 

The coumarins (warfarin, acenocoumarol and 
phenindione), which are classed as vitamin K 

Dabigatran and rivaroxaban, which are the non- 
vitamin K antagonists. 

Heparins are used first-line where immediate 
anticoagulation is required, and in those who have 
contraindications to warfarin. However, as 
warfarin takes between 48 and 72 hours to have 
its full effect (because of the differing half-lives of 
the clotting factors that warfarin affects), it is 
started in hospital at the same time as heparin, 
with the heparin subsequently withdrawn. 

Dabigatran and rivaroxaban, the newest 
anticoagulants, are direct thrombin inhibitors 
with two major advantages over previous 
anticoagulants in that they are orally available 
and require no therapeutic monitoring. At present 
both are licensed only for venous thrombo- 
embolism prevention after hip or total knee 
replacement surgery. 

Aspirin is also used for stroke prevention. It 
targets the arachidonic acid pathway by 
irreversibly inhibiting cyclo-oxygenase to prevent 
thromboxane production, which causes a 
reduction in 'platelet stickiness' that lasts for the 
platelet lifetime. Warfarin acts on the proteins in 
the clotting cascade. 

Nice Guideline 36 contains a stroke risk 
stratification and thromboprophylaxis algorithm: 

aspirin (75 to 300mg/day) is indicated in 
those with low risk of stroke 3 or when there is 
uncertainty about stroke risk and the patient is 
awaiting specialist assessment and there are no 
contraindications 1 

© warfarin is indicated in those at high risk of stroke 

both aspirin and warfarin are indicated in those 
at medium risk. 3 

Factors that increase stroke risk are older age, 
hypertension, diabetes, a previous thrombo- 
embolic episode or other heart disease. Each 
patient should be individually assessed to ensure 
the safest treatment. 

It has been shown that warfarin is more 
effective than aspirin for stroke prevention in those 
with AF, even taking into account the increased 
intra- and extra-cranial bleeding risk. In AF 
(medium to high risk of stroke) warfarin reduces 
stroke and other vascular risk by about 33 per cent 
compared with anti-platelets 1 and this increases to 
66 per cent in those over 75 years. 1 Warfarin and 
aspirin should not be combined as no additional 
benefits are seen and bleeding risk increases. 

Clopidrogrel is not licensed or indicated in AF 
stroke prevention. 1 

Carboxylation of glutamic acid residues during 
the clotting cascade leads to production of 
prothrombin and factors VII, IX and X. Vitamin K 
is the co-factor in this reaction. 

Warfarin blocks the action of vitamin K epoxide 
reductase, therefore stopping this carboxylation. It 
takes about three days to have full effect as it only 
works as new clotting factors are produced, with 
no effect on existing clots. The clotting factors are 
synthesised in the liver. 

Warfarin is metabolised by hepatic microsomal 
enzymes, so clearance is reduced in liver disease. 
It is excreted renally. It has a plasma half-life of 
about 37 hours and is readily absorbed from the 
gastrointestinal tract, and it needs to be taken 
daily at the same time, usually around 6pm. 

What is an INR? 

The International Normalised Ratio (INR) 
indicates the time blood takes to clot. The higher 
the number, the longer clotting takes. A normal 
INR is one, and therefore an INR of two means 
that the blood takes twice as long to clot. 17 

27.03.10 CWJ- 

Different degrees of anticoagulation are required 
in different conditions, which are determined and 
listed by the British Committee for Standards in 
Haematology (BCSH) 4 The target in AF is 2.5, but 
a range within 0.5 units of the target is acceptable. 5 

Patients are started on a loading dose of 
warfarin until the INR target is reached and then 
the dose is reduced. A maintenance dose is usually 
between 3mg and 9mg daily. The INR is monitored 
frequently during the initial treatment period to 
ensure that the correct level is being reached. This 
is usually daily until in the therapeutic range for 
two consecutive days, then twice weekly for one or 
two weeks, then weekly until stable, then every six 
to 12 weeks. 6 

More frequent testing is indicated in illness or 
other change in the patient's condition or 
medication. Once the patient is stable, which can 
take months in some cases, INR testing is reduced. 
At any stage, dosage changes may be made as 
required. Devices that enable patients to self-check 
their INR, such as CoaguCheck, may be suitable in 
certain cases. 

All brands of warfarin are the same colour for 
each strength (0.5mg is white, 1mg brown, 3mg 
blue and 5mg pink). Some hospitals and PCTs have 
limited the strengths prescribable to reduce the 
risk of over and under-dosing. 

Need specific CPD resources? Check out our clinical index 

■ 'clinical inc ■ .■■ 


There are two main types of interaction: 
» Pharmacokinetic - these occur mainly because 
warfarin is bound to plasma protein in the 
circulation, so has an increased effect if displaced 
by other drugs, such as diuretics, anti- 
inflammatories, amiodarone and oral anti- 
diabetics. In many cases, the dose can be adjusted 
to take this into account. 

Pharmacodynamic - bleeding risk increases 
without change of plasma warfarin concentration, 
eg when paroxetine is co-administered. 

As metabolism occurs via the P450 2C9 system, 
any medications also metabolised by this system 
will affect warfarin. Inducers of this enzyme 
system, such as rifampicin and carbamazepine, 
increase warfarin needs, while inhibitors such as 
macrolides reduce warfarin needs. 

The BCSH guidelines state that where a drug 
change lasts more than five days, the INR should 
be checked one week after the drug change and 
warfarin adjusted accordingly. 7 

The table, above right, is not an exhaustive list 
of interactions, so the BNF and Stockley's Drug 
Interactions should be consulted. 

Paracetamol is regarded as safe to use with 
warfarin: however, studies give conflicting reports 
as to how it affects the INR. More research is 
needed to clarify whether increased INR monitoring 
is needed with this combination. 11 Orlistat reduces 
vitamin K absorption, so there is less vitamin K to 
act on and warfarin needs are reduced. 

Acute illness and weight loss exaggerate the 
response to warfarin. Warfarin needs are increased 
in thyrotoxicosis and reduced in hypothyroidism. 8 

Many popular herbal and alternative medicines 
also interact with warfarin and should be avoided. 
These include glucosamine, chondroitin, ginseng, 
ginkgo biloba and ginger. 6 Coenzyme Q10 
reduces warfarin effect as it has a similar 
structure to vitamin K. St John's wort reduces 
warfarin's effect because of its action as an 
enzyme inducer. 

Table 1 . Warfarin interactions 

Drugs potentiating warfarin effect 

Drugs reducing warfarin effect 


Barbiturates (enzyme inducer) 

NSAIDs and aspirin 

Phenytoin (enzyme inducer) 


Cholestyramine (by absorption of warfarin) 

Erythromycin, azithromycin, clarithromycin 







Oral contraceptives 






Warfarin patients should follow the usual healthy 
eating guidelines, but it is important that the 
amounts of vitamin K-containing foods in the diet 
is not varied too widely on a day-to-day basis as 
this will result in an unstable INR. Foods with high 
vitamin K include green leafy vegetables, such as 
cabbage and Brussels sprouts, broccoli and 
spinach. There are smaller amounts in meat and 
dairy products. Vitamin K is also synthesised by 
gut bacteria, which is why illness and anything 
affecting these bacteria, such as antibiotic 
treatment, may affect the INR. Cranberry and 
grapefruit increase INR so should be avoided. 
Alcohol can inhibit the liver enzymes, requiring a 
reduced warfarin dose. 5 Enteral feeds can also 
affect warfarin levels. 

Adverse effect s 

The greatest risk in warfarin treatment is that of 
overdose and haemorrhage, which can occur even 
in the normal therapeutic range. Patients should 
be reminded of the need to seek medical 
attention should they notice any of the following: 
prolonged bleeding from cuts; bleeding that does 
not stop by itself; nose bleeds; bruises under the 
skin; bleeding gums when brushing the teeth; red 
or dark brown urine; red or black stools; coughing 
or vomiting blood-stained fluid; or heavy or 
increased bleeding during menstruation. 9 

Warfarin reversal 

Vitamin K 1 (phytomenadione) is given by the IV or 
oral route, depending on the INR and presence of 
haemorrhage. However, between INR 6 and 8 
where there is minor or no bleeding, warfarin is 
stopped and then recommenced when the INR 
reaches below 5. If the INR is less than 6 but 
more than 0.5 units above target value, warfarin 
dose is reduced or stopped until back in range. 10 

Fresh frozen plasma or prothrombin complex 
concentrate can also be given in severe cases of 

Anti-coagulation clinics 

The white paper, Our Health, Our Care, Our Say: a 
New Direction for Community Services, promotes 
pharmacy as a suitable place for anti-coagulation 
services and indeed many PCTs commission such 
a service. There are specific guidelines including 
training needs, patient inclusion criteria and 
dosage change guidelines. Sheffield PCT provides 
such a service; see its protocol on the PCT website. 

Latest advice 

In December last year the MHRA issued updated 
guidance to supplement advice issued by the 
National Patient Safety Agency. The aim was to 
improve safety with and for everyone involved in 
warfarin monitoring, supply and prescribing. 
Pharmacists should check with every patient 
presenting warfarin scripts their current INR and 
warfarin dose, and that their INR is monitored. 
Without this, pharmacists should satisfy their 
professional judgement before handing out 

Patient education 

Patients have a lot of information to take in when 
starting warfarin therapy, but the pharmacist is in 
a good position to follow up their understanding 
by ensuring that they know their dose, checking 
for interactions and adverse effects, and providing 
on-going reminders of diet and lifestyle advice. 
Patients should carry the yellow anticoagulation 
card and have a yellow patient information 
booklet and current treatment sheets with doses. 
References and further reading are online at 

Rosemary Blackie MRPharmS is a community 
pharmacist in Sheffield. 

Download a CPD log sheet that helps you 
complete your CPD entry when you 
successfully complete the 5 Minute Test for 
this Update article online (see opposite). 


9 Part two of our pregnancy series 

looks at physiological changes 
during the second trimester 


Sign up for the clinical newsletter and get Update emailed to you 



How long does it take for warfarin to have its full effect? 
What is the target INR in atrial fibrillation 7 Which drugs 
can reduce the effect of warfarin? 

This article describes the use of warfarin in atrial 
fibrillation. It includes information on how warfarin 
works, INR values and dosage adjustment, drug and 
dietary interactions and adverse effects. 

Find out more about oral anticoagulants including how 
treatment is started, interactions, lifestyle advice, self- 
testing and management, on the Clinical Knowledge 
Summaries website at 

Read the information for community pharmacists on 
the National Patient Safety Agency website about 
actions that can make anticoagulant therapy safer at 

Find out more about how diet and nutritional 
supplements can affect anticoagulant therapy and the 
advice you could give to patients, from the leaflet on the 
Atrial Fibrillation Association website at 

■ For further learning the CPPE has a programme, 
Anticoagulation - Focal Point, available at or on 0161 778 4024. 

Are you confident in your knowledge of warfarin therapy 
and dosage adjustments? Could you give advice about 
drug interactions, adverse effects and the effects of diet 
and nutritional supplements? 

on the C+D website at 


Use your PIN to complete the assessment online. Your test score will be 
recorded. If you successfully complete the 5 Minute Test online, you will 
be able to download a CPD log sheet that helps you complete your CPD 
entry at 

Registering for Update 2010 costs £37.60 (inc VAT) and can be done easily 
at or by calling 0207 921 8425. 

Signing up also ensures that C+D's weekly Update article is delivered 
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Get a CPD log sheet for your portfolio when you successfully complete 
the 5 Minute Test online. 

Practical Approach 

Prescribing for hypertension 

David Spencer, pharmacist at 
the Update Pharmacy, receives a 
phone call from Dr Mo Merali, to 
whose CP practice David provides 
prescribing advice. 

Mo says: "David, we've taken on a 
young trainee CP who was 
previously a hospital house officer. 
I'd like you to help train her for 
prescribing in primary care. She's got 
a nice case to start off with. Can I 
send her along to you?" 

David agrees. When the trainee 
arrives David asks her to outline the 
case to him. 

She replies: "The patient is a 
woman in her mid-40s who came in 
for an insurance medical. She has 
asthma and is on inhaled 
beclometasone regularly and 
salbutamol prn. 

"I found the patient's BP to be 
rather high - around 170/100 - and 
apparently there's a family history of 
hypertension. She had hypertension 
during her pregnancies and is slightly 

David asks: "So, have you 
prescribed anything yet?" 

"No. I've asked her to come back 
next week so I can double-check that 
her BP is raised, and I'll prescribe 
something if it is. That's also given 
me the chance to work through the 
case with you." 

1. What is the target blood 
pressure for people with no 
complicating conditions? 

2. What is the target blood 
pressure for patients with 
diabetes or cardiovascular 

3. At what BP level is it 
recommended that 
antihypertensive treatment 

should be initiated in patients 
who do not have diabetes or 
cardiovascular complications? 

4. Assuming that the second BP 
measurement confirms the first, 
should this patient be prescribed 
antihypertensive medication? If 
so, why; if not, why not? 

5. What are the Nice 
recommendations for prescribing 
antihypertensive drugs? 

6. If antihypertensive medication 
is considered necessary for this 
patient, what should the first 
choice drug(s) be? 

7. Which antihypertensive drugs 
should not be prescribed for this 
patient, and why? 

8. Whether antihypertensive 
treatment is necessary for this 
patient or not, what other advice 
should be given? 

1. Below 140mm Hg systolic and 
90mm Hg diastolic. 

2. Below 130/80. 

3. Above 180/110. 

4. Yes. Although the patient's BP is 
below the level in question three, 
she has a family and a personal past 
history of hypertension. She is 

therefore at greater risk of stroke 
and possibly heart attack so should 
be treated. 

5. This is commonly known as 
the ACD guideline. Step 1 for 
patients under 55 years is an 
ACE-inhibitor or angiotensin-ll 
receptor blocker (A); for over 55s, 
calcium channel blocker (C) plus 
diuretic (D). Step 2, for all ages if 
Step 1 is unsuccessful, A+C or A+D. If 
Step 2 is unsuccessful, A+C+D. If this 
is unsuccessful, add further diuretic 
or an alpha-blocker or beta-blocker. 

6. ACE-inhibitor or angiotensin 
receptor blockers. 

7. Beta-blockers, as they can 
precipitate asthma. 

8. Emphasise the importance of 
lowering and controlling her BP and 
point out the risks of raised BP. 
Encourage her to take ownership of 
her condition and monitor her own 
BP. Lifestyle measures, including 
weight reduction, should help to 
lower BP. 

This article :an help with these 
CPD competencies: Gla, Glc, Gld, 
Gle, Gls, G2h, G6f, G6p, Cla, 
C4b, C4c. 

See ;, 5- r ox7b 19 

NAL 27.03.10 

Have you experienced something similar? How did you resolve it? 
Email C+D at 


This series aims to help you make the right decisions when confronted by an ethical dilemma. In the last issue of every month we present a scenario likely to 
arise in a community pharmacy and ask a practising pharmacist and/or a member of the Pharmacy Law and Ethics Association (PLEA) to comment on the 
legal and ethical implications of the actions open to you. Readers are invited to have their say at 

Can you supply a POM 
pack of EHC off script? 

e tried to obtain a P pack from our 
nearest branch but this was not 
practical given the distance and 
resources. We considered giving Miss X an 
emergency supply as she could not get to her CP. 
She had bought Levonelle previously, but this 
evidence could not be used as the basis of an 
emergency supply. In the end our wholesaler 
kindly provided a supply that afternoon despite 
having missed our deadline. 

An emergency supply can be made during working 
hours if a patient cannot get to a GP, but they 
should have previously been prescribed the 
medication. Having the medication before from 
a pharmacy under a patient group direction is 
not sufficient basis for an emergency supply. 
Patients must have had the medicine prescribed 
by their CP. 

This is an interesting dilemma; although 
pharmacists want to extend their role and get 
more involved in delivering services, as the law 
stands we might end up being unable to support 
people such as Miss X. When new services are 
introduced perhaps we should pay a little more 
heed to any such unintended consequences. 

You cannot modify a POM pack by inserting 
additional leaflets to enable a P sale. So a sale for 
the Levonelle POM pack could not be made even 
though it could have included the same 
information as in the counter pack. Despite being 
exactly the same drug, the POM version is 

licensed as a POM, so must be supplied on script. 
Hiren Satra MRPharmS is a locum with Manor 
Pharmacy Croup in Herts. 

Section 58 of the Medicines Act 1968 provides 
that a POM can only be sold or supplied in 
circumstances corresponding to retail sale by a 
pharmacist in accordance with a prescription from 
an appropriate practitioner. 

There are exemptions to this prohibition. For 
example, the POM (Human Use) Order 1997 
permits emergency supplies in certain 
circumstances if requested by a patient. An 
emergency supply of up to 30 days of a POM can 
only be made at the request of the patient if: the 
pharmacist has interviewed the patient; there is 
an immediate need; the treatment has been 
prescribed previously; and the dose requested is 
appropriate. In this case the patient would not 
satisfy those criteria, so an emergency supply 
could not be made. It would therefore have been 
unlawful to supply a pack marked POM, even if 
there is an identical licensed P version. 

The pharmacist could have tried to contact the 
patient's GP to ask if he would write a prescription 
following a telephone consultation. That 
prescription could then be faxed to the pharmacy 
with an original copy posted. The Code of Ethics 
has guidance on dispensing medication against a 
fax. Alternatively, the patient could have got a taxi 
to the GP or another pharmacy. The pharmacist 
should record the consultation and his decision, 

with reasons, in the patient's PMR. 

Noel Wardle is a solicitor at Charles Russell 

LLP, specialists in pharmacy law. 

This article can help in the following CPD 
competencies: C1g, C1h, Glk, G3n. See 

More dilemmas are online at www.chemist 


PLEA is an association of 
pharmacists interested in 
law and ethics, and lawyers 
or ethicists specialising in 
pharmacy, with the aim of promoting 
understanding of the ethical basis for 
professional judgement 

Next month's Ethical Dilemma 
The ethics of medicine BOGOFs 

We need more Ethical Dilemmas. If you have 
an interesting scenario that you can share 
with your fellow pharmacists, get in touch 


All the action of solid medicines 
perfectly executed in liquid form. 

j -At,* ki » , a 


• m 

■ i.* - it*, t * 


?' 1 '• 

Rosemont see no reason why you should have to 
compromise on the quality of medication needed by 
patients with swallowing difficulties. 

For over 40 years Rosemont has developed a diverse 
range of over 90 different oral liquid medicines for 
patients who battle to swallow traditional solid 
formulations. Rosemont products are easy to take 

and consistently achieve the desired performance, 
matching that of a solid formulation. So your patients 
never feel out of sync. 


The source of liquid solutions 

Rosemont Pharmaceuticals Ltd. Rosemont House. Yorkdale Industrial Park, Braithwaite Street, Leeds LS I I 9XE T +44 (0) I I 3 244 I 400 F +44 (0) I I 3 245 3567 
E Sales/Customer Service: T +44 (0) I I 3 244 I999 F +44 (0) I I 3 246 0738 W 

Information about adverse event reporting can be found at Adverse events should also be reported to Rosemont Pharmaceuticals Ltd on 01 1 3 244 1400. 


View the category M archive 

Category M Barometer 

Generic Eric reveals how the second tariff for 201 will affect your business 

or the first time in 15 months, the 
category M tariff has seen a positive 
increase in overall reimbursement. 
This addition is between £17 million and £20m, 
once market growth has been factored in, and will 
boost the average pharmacy's generic purchase 
profits by £1,425 over the next three months. 

There has been a large amount of activity in the 
category this quarter, with only three products out 
of 433 staying at the same reimbursement level 
as in quarter one. Ninety six were reduced and 
334 increased. 

Most of the savings in the £1.45 billion basket 
have been made to those products added to the 
tariff this year. The largest decrease this quarter 
sees 76 per cent being removed from the tariff 
price of topiramate 200mg tablets; the largest 
increase is on fluoxetine 20mg capsules, at 67 
per cent. 

A further two products, furosemide 25mg x 250 
and oxytetracycline, have been removed from the 
category. Nine have been added, the most 
notable of which is clopidogrel, an addition which 
it is estimated will save the NHS £62m a year. 

The Category M Barometer has increased 
from 107.7 in quarter one to 109.6 for quarter two. 

On the most commonly dispensed lines by 
volume, reimbursement prices have increased on 
the majority of lines this quarter. In fact, an 
annualised amount of £33m has been added to 
these lines, or £8.25m per quarter. 

For the average pharmacy, this equates to 
£264 a month added to the bottom line (if whole 
market volumes are used and just the top 20 lines 
are dispensed). 

£17-20m added this quarter 

VV S Hull 5 1 IIH l> t 



The 10 products with the larg 

est rise in price 


price (£) 

price (£) 



Fluoxetine 20mg capsules 







Ranitidine 300mg tablets 







Cimetidine 400mg tablets 







Amiodarone 200mg tablets 







Amiodarone 100mg tablets 







Aciclovir 5% cream 







Pravastatin 10mg tablets 







Fludoxacillin 250mg capsules 







Hydrocortisone 1% ointment 







Ranitidine 150mg tablets 







vVIILlL is ilUL 



The 10 products with the larg 

est iiirn price 


price (£) 

price (£) 


Topiramate 200mg tablets 






Pantoprazole 40mg tablets 






Topiramate 100mg tablets 






Pantoprazole 20mg tablets 






Topiramate 25mg tablets 






Clopidogrel 75mg tablets 






Topiramate 50mg tablets 






Co-amoxiclav 250mg/62mg/5 

ml SF susp 

100ml 4.91 




Co-amoxiclav 125mg/31mg/5 

nl SF susp 

100ml 3.71 




Mirtazapine 15mg tablets 






Data and analysis supplied by Actavis 


Available in electronic format 
and in a print-friendly version for download. 

MsRe"' was established in 1 990 and produces severa 

publications: MeReC Bulletin, MeReC Extra, MeReC Monthly and 
'blog style' MeReC Stop Press and Rapid Review. Publications and 
related resources are available on our website. 

National Prescribing Centre 





Focuses on key therapeutic 
dilemmas -collating and 
summarising evidence and 

Summarises the other MeReC outputs, 
including our'blog' publications, MeReC 
Rapid Review and MeReC Stop Press, 
and highlights new materials available 
on oureLearning platform: 

A regular monthly compilation of the 
the 'best of the blogs', Rapid Review and 
MeReC Stop Press. This gives readers a 
monthly compilation of new news and 
research set into the context of the rest 
of the evidence and guidelines. 


These weblog or 'blog' publications 
are quick, succinct commentaries on 
recent newsworthy prescribing and/ 
or medicines-related issues They are 
available on: 


All MeReC publications are available on the NPC website at: WWW.npC.CO.Uk/ebt/mereC.htm 

MeReC Publications support the National Institute for Health and Clinical Excellence (NICE) clinical 
guidance programme and implementation strategy. They are accompanied by a range of education 
and implementation resources/tools to facilitate the uptake of key messages contained within the 
MeReC portfolio. These are available through NPCi (wwwxapcLorg,iok). 

Would you like to receive MeReC publications electronically as they become available? 

Register now for a 




Registration is free - simply visit 

and follow the 
step-by-step instructions. 

You control your own account 
via the NPC website, keeping 
personal and contact details up- 
to-date and selecting areas that 
are of interest to you. 

We will send regular alerts 
to you, highlighting what is 

available for your areas of 
interest and how to access it. 


Write the perfect CV, work abroad or be a great pre-reg tutor. Find out how @ 

0207 921 8123 

Booking and copy date 
12 noon Monday prior 
to Saturday publication 
subject to availability 

Contact: Andrew Walker 
Tel: 0207 921 8123 
Fax: 0207 921 8132 

Ludgate House 
245 Blackfriars Road 
London SE1 9UY 


Work available within community, hospital, PCT, 
HMP, 100 hour and supermarket pharmacies. 

Excellent remuneration obtained 
Hours to suit 

contact with availability/enquiries 
Margaret/Tracy: Text 07760 7771 19 
Tel: 01274 621133/621 100 

Businesses requiring cover please contact as above. 
Emergency cover provided nationwide. 
' ■ . (BFD) 

Finding your own direction 

This month I'm making some big - and exciting - decisions 
about where I want to take my career in the future. And as you 
can expect, at Boots UK I'm spoilt for choice - from different 
locations and types of stores around the country, to a move 
into management. 

Find out what choices Jina's making 
this month and about joining us as a 
Pharmacist or Pharmacist Store Manager 


feel good 


Enthusiastic Pharmacists 
required to manage and 
provide the full range of 
services in our established 
and well supported branches 
within the Oxfordshire and 
Bedfordshire areas. 


Send your CV by email: 
or call on: 
01582 560393 


Pharmacist Managers / 
Pre Reg Students (Nationwide) 

Regional Sales Managers/ 
Relief Dispensers (Midlands) 

Please apply by CV to: 


Browse jobs, upload your CV and get careers advice 

27.03.10 JOBS 

My pharmacy life 

Anna Creswell describes her work as a Lloydspharmacy network 
development manager and the career path that took here there 

As a Lloydspharmacy 
network development 
manager my role is to 
implement change across our 
pharmacy network. My team and I 
take new initiatives and projects and 
ensure they're designed and 
implemented as well as possible, to 
ensure maximum engagement from 
the pharmacy teams. 

Recently I have been working on 
our express repeat prescription 
service, online doctor service and flu 
vaccination. When someone comes 
up with a new project or initiative, I 
put together, with the assistance of 
others, a business case as to whether 
it's going to be viable in terms of, for 
example, training, cost and IT 
support. My role, apart from to make 
the initiative happen, is to represent 
the individual user. 

For example, the express repeat 
prescription service started off being 
quite a complex process, and we 
tried to pull back so that it was as 
simple as possible for pharmacists to 
do as quickly as possible - we know 
that our pharmacists are very 
pushed for time I'm not the decision 
maker as to whether we go with it or 
not, but I am there to ensure the 
time impact on the network is as 
negligible as we can make it. 

I have been in this role since the 
beginning of 2009, after working in 
our pharmacy network support team 
for three years. I originally started 
out doing a cosmetic chemistry 
degree but realised that I was much 
more geared to a customer-facing 
role; becoming a pharmacist seemed 
like a good step in order to do the 
science but have a customer focus. 

I started off as a hospital 
pharmacist but quickly recognised 
my skills lay in operation and process 
rather than as a clinical pharmacist, 
and then a role came up opening one 
of Lloydspharmacy 's managed care 
centres, dispensing for care homes. It 

Anna Creswell: sense of achievement 

bridged the gap between hospital 
and community and enabled me to 
get on a career path. I was in that 
role for 18 months before joining the 
pharmacy network support team. 

Now I have recognised what I'm 
good at and I'm going in the right 
direction, so I am really pleased. I 
have been through a convoluted 
route to get here but if I hadn't I 
probably wouldn't be here, so I have 
no regrets at all. 

The nice thing about my role is 
that it's incredibly varied. A typical 
day might involve working with the 
IT department on the design of a 
new system, giving the operations 
input as to what we want it to 
achieve and look like. From there I 
might go to a training meeting or 
work on marketing or PoS material. In 
between I'll be answering queries 
from individual pharmacists. 

In my spare time, I enjoy shopping 
and going out for dinner with family 
and friends, and I love reading. 
Because we have lots of things going 
on at a time at work, reading is the 
one thing you can do that stops you 
thinking about work. It takes my 
mind off things. 

I remember the very first project 
that I had ownership of; I booked 37 
training events across the network 
and I lay awake at night thinking, 

had I booked the hotel properly, or 
were people going to turn up on the 
wrong day? You have got to get it 
right, you can't mess up. You get 
used to that pressure and put 
processes in place so you don't 
make mistakes, but when you stop 
to think that what you're doing 
affects so many people in their jobs, 
that can keep you awake at night. 
You're always thinking, have I got it 
right? Is what we've designed going 
to work and be liked by our 
pharmacy teams 7 

That's what motivates me - 
making sure that everything we do is 
right for the pharmacy team. When 
you get it wrong it's incredibly 
deflating, but when you get it right 
it's so exciting - when we've 
launched a new initiative and the 
pharmacy teams say they like it, and 
then they start doing it and you start 
seeing results coming through, it 
gives me a real sense of achievement. 

Last year just getting this role was 
a huge achievement for me, but also 
I think we have launched some 
pretty big initiatives this year that 
have been pretty successful and the 
pharmacists have said, yes, this is 
what we should be doing 

In 2007, while I was in the 
pharmacy network support team, I 
won a support manager of the year 
award. That was a really big highlight 
because we do a lot of work in head 
office and sometimes you feel you're 
plugging away and not sure people 
are noticing what you're doing, so to 
be recognised as someone who 
supports the network in a positive 
way was really important to me. 

What I want to do in the future is 
increase my influence to ensure what 
we put into the network is the right 
thing, become more of a decision- 
maker rather than the person that 
goes away and makes it happen. I'd 
like to have more influence over 
what we do and when we do it. 


... attheRPSGB 

The RPSCB has invited nominations 
for an expert panel to advise the 
future professional leadership body 
on scientific strategy. The Society 
last week announced the 
establishment of the Pharmaceutical 
Science Expert Advisory Panel to 
lead on "scientific strategy, 
leadership, advocacy, assessment 
and review". Candidates would be 
drawn from "a wide range of 
disciplinary and professional 
settings", the Society said, and could 
include non-pharmacists and non- 
UK residents. For more information 
on the selection criteria and 
application process, visit www.rpsgb. 
org/worldof pharmacy/research. Clarity DTP 
A new online 
direct to 
pharmacy (DTP) 
distributor has 
appointed a 
expert as joint 
managing director. Paul Forster- 
Jones (pictured) joins Clarity DTP 
from the Co-operative Pharmacy, 
where he was retail director. Mr 
Forster-Jones has previously held 
board positions with both AAH and 
Alliance Healthcare. The appointment 
signalled Clarity DTP's "intentions 
for growth", the company said. 

... attheABRHP 

Six appointments to an independent 
advisory body for the regulation of 
homeopathic remedies include a 
community pharmacist and a 
lecturer in pharmacy practice. The 
MHRA and the independent 
Appointments Commission last 
week announced the following unpaid 
four-year appointments to the 
Advisory Board on the Registration 
of Homeopathic Products (ABRHP): 

• David Needleman, community 
pharmacist and homeopath 

« Alan Worsley, principal lecturer of 
pharmacognosy and pharmacy 
practice, University of Sunderland 

• Gillian Eccleston, professor of 
pharmaceutics, Strathclyde University 
» Andrew Farrow, patient/carer 
governor, Salisbury Hospital NHS 
Foundation Trust 

• Gary Smyth, CP and homeopathic 

• Dominic Williams, senior lecturer, 
Centre for Drug Safety Science, 
University of Liverpool. 



Know what job you want - get personalised jobs by email 


Pharmacist opportunities 

...when you're in-store, you can do more. Every day our 
Pharmacists help their customers (and colleagues) in all kinds of 
ways, from curing cracked heels to fixing wobhly trolley wheels. 
In-store means in touch - with your pharmacy colleagues, 
the entire store team, 170,000 like-minded Asda people and 
18 million customers. And in-store also means in control, as you 
enjoy the freedom to develop your community pharmacy your way. 
So whether you're behind the counter or out in the aisles, you're 
always ready to add more value to your customer's day. 
That's pharmacy... the 

For more information and to apply visit 

We respect all our colleagues and value their differences. 
We do not tolerate any form of discrimination or harassment. 


Urgent Care Cambridgeshire 
Chesterton Medical Centre 
Union Lane, Chesterton 
Telephone: 01223 726050 Fax: 01223 726051 

Community Pharmacist 

Urgent Care Cambridgeshire is an Out of Hours GP led service based in the county 
of Cambridgeshire. We will shortly commence our new contract with the NHS 
Cambridgeshire PCT providing the service to the whole of Cambridgeshire. 
Cambridgeshire County has a population of approximately 613,000. We currently 
have 5 Primary Care Clinic locations (Wisbech, Doddington, Ely, Huntingdon and 
Cambridge). We require a community pharmacist to provide medicine 
management for the medical products used within the organisation. 
We will maintain our own stock and pre-package and label the prescriptions. We 
plan to open a pharmacy in Cambridge and you will be a key member in the 
development of this service. 

If you are interested in applying, please send a covering letter and your C.V. to 
the HR Manager 

on a Full Time/Part Time basis 

for busy village pharmacy on the edge of 


Contact Ben on: 

01225 314301 

or email: 

Tired of taking 
the same route? 

Let C+D jobs provide an 
effective alternative. 

To advertise your vacancies visit 


Having trouble finding the right staff? 


0207 921 8123 

Contact: Andrew Walker 

@ 15 
(t) Natio\ 


Concept, design & planning 
Manufacture, fitting & installation 
The Pharmacyjrefitispecialists • 0800 970 0102 



We have just produced 

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Just some of the insider secrets we will be sharing with you. 

To obtain your copy simply 
Call Janine on: 01494 722224 


Visit our Website, to download the report: 


"We are the only NPA 
approved supplier for 
selling your pharmacy" 

Hutchings Consultants Ltd 


Approved Supplier 

the legal prescription 

Cost effective specialist legal advice 
to independent retail and community 

We can assist with buying, selling, merging 
and demerging pharmacy businesses as 
well as related leases, sales and purchases 
of commercial premises 



UP Contact 

Hilary D'Cruz or Jas Singh 
01543 466 660 


40,527 unique user 

Worried about the Credit Crunch? 

DTP Will it get better? 

Quick sale guaranteed! 

For further information please contact 
Colin Caunce on 07966 524162 


Chemist+Druggist remains the clear leader 
in influencing stock decisions* 

*Linda Jones Associates Industry Survey 2009 



Let employers come to you - publish a CV 

•of le 


Have you ever thought 
about selling mobile 
phones, but get put off 
by the costs involved? 

Introducing Camera Phone Zone, the easy, no fuss solution that has helped more than 300 
retail outlets and dozens of pharmacies enter the mobile phone business. 

Thanks to a close tie-up with Vodafone, one of the leading mobile phone networks in the 
world, Swains International Pic are able to help you on your way to more footfall, more sales 

and more margin! We provide a range of the latest pre-pay Vodafone handsets, at competi 

tive prices and with no tie-ins. There are even incentives and freebies for you, the retailer, to 

make life that little bit sweeter. 

ML* © 

^ 5/l *5U(Vc 

Get featured on 

All you have to do is take an initial order of 1 2 or more 
handsets, including at least four different models. In 
return, we will provide you with all the in-store display 
material you need. This includes dummy phones and 
slat wall stands, which allow your customers 
to see what's available, whilst keeping valuable 
stock safely out of harm's way. A2 posters with 
the latest offers and promotions will help pull in 
the crowds, as will POS directly from Vodafone. 



■ili! ■ M, 

■ ■ 

I % 

9 i. i_a 

This month, customers can get a free earphone tidy with every purchase. Just one in a long 
line of exclusive deals available to every CPZ Swains also run regular advertising in the con- 
sumer / specialist press to promote the independent retailer. We will even pay up to 50% of 
any advertising you wish to run in your area. 

Fun Earphone map 

1 If an item is in stock, we can have it to you within 48 hours and if things do go wrong, or 
| even if you just have a query, we offer a full customer service back up. 

1 All this with no other commitment than to maintain a level of 1 2 handsets! 
1 You really have nothing to lose. 



Contact Swains International Pic for more information 
Tel : 0845 450 4242 Free Fax: 0800 652 9100 

Having trouble finding the right staff? 


^ ® 




High grade Glucosamine 
and Chondroitin 

Young and old alike, 
stay flexible, agile and 
mobile all day long 

With Turmeric; 
natures natural 

For further information please contact us: 

Tel: 020 8426 3400 




School of 

in partnership with 



S|p> -^board: sign up now 

for the 2010-1 1 pre-reg 
training programme 

Springboard is a pre-registration programme offered by 
Medway School of Pharmacy in partnership with C+D. 
Springboard equips pre-registration students with the skills 
and confidence to ensure a smooth transition from pharmacy 
graduate to practicing pharmacist. 

The Springboard pre-registration training programme consists 
of eight study days facilitated and delivered by staff from C+D 
and Medway School of Pharmacy covering a wide variety of 
topics, enabling students to meet the appropriate competencies 
in the RPSGB's student handbook. 

Springboard is unique in that by the end of the course the 
students will have also completed an accredited medicines 
use review training programme, the C+D Counterpart 
pharmacy assistant course, the Practice Certificate in Pharmacy 
Management course, as well as receiving a subscription to an 
online practice exam question website. 

Springboard also includes a training day for the 
pre-registration tutor. 

The cost of Springboard is from £1,200 (+ VAT) per student. 

For more information phone 0207 921 8413 
or email 






A breakthrough in 
property purchase relief 

If you are planning to buy a pharmacy, 
modiplus can help you with: 

:: The negotiation process 

:: The process of buying goodwill and stocks 

" The process of buying the entire share capital 

Profit and cash flow projections 
- Tax considerations 

Loan applications 

Recommending pharmacist specialist firm 
of solicitors and stock-takers 
VAT and PAYE registration etc. 

^ ^ / am glad I moved to mi « 1 1 pi us to help 
me with the purchase of my first pharmacy. 
They have saved me large amount of tax 
and interest on the loan by negotiating 
a good deal because of their experience. ^ ^ 

For more information or for a 
FREE consultation please call Umesh 

on 020 7383 3200 

P iEaa modi plus** 




Got a story for Postscript^ 

Cellar yields 
treasure trove 

Postscript is always a fan of pharmacy 
memorabilia, so it was amazed when it was sent 
the picture (right) of Paton and Finlay Pharmacy, 
in Bruntsfield, Edinburgh. 

The store's window display was created after 
staff ventured down into the pharmacy's cellar, 
uncovering an Aladdin's cave of ingredients jars, 
medical devices and assorted pharmaceutical junk 
that dated back to the early 1900s. 

The display includes everything from Boots' 
own brand boracic ointment, to a crystal 
atomizer, a cartridge syringe, and even an old and 
battered pharmacopaeia. 

Do you have some hidden treasures in your 
pharmacy? Email postscript@chemistand and let us know. 

Competition winner 

Congratulations to Lloydspharmacy's Sue Fray, 
of Caerphilly Road, Cardiff branch, who knew 
Steve Churton is the current president of the 
RPSGB, not Buffy the vampire slayer. Ms Fray, 
who was randomly selected out of all correct 
answers, wins a copy of the Fasttrack guide to 
Pharmaceutics. Not that anybody got the 
question wrong, mind... 

C + D Reader of the week 

t Country locum Kevin Moseley talks crazy golf, Norwegian sea 
and how to grow a plant from soap packaging 

If you weren't a pharmacist, what would you 
have been? I've been asked before but I don't 
know. I've got an analytical mind, so maybe 
something involving maths or physics. I'd 
probably be trying to crack one of the great 

What's your favourite sport? I'm a keen pool 
player, and I play tennis, but mainly it's playing 
crazy golf. For five years I've been taking part in 
competitions around the country - I've taken 
part in the World Tournament in Hastings. So far 
this year I've come second in tournaments in 
Birmingham and Bristol. 

What's your guilty pleasure? Apart from 

chocolate? Musically, I'm a staunch indie fan. 
But I like the Beach Boys. 

How would yowr wife describe you? 
Intelligent but stupid. Slightly eccentric. Quite 
comical. More education but little common 
sense - which is not useful when doing DIY. 

What are you reading at the moment? 
I'm in the middle of Bad Science by Ben 
Coldacre, which has helped me hone my own 

thoughts on things like homeopathy. I'm also 
reading Sea Dog Bamse, about a dog who was 
the mascot of the Norwegian Navy in World 
War 2. 

Do you do anything other than pharmacy? 

We make handmade organic soaps and skincare 
products. We keep it as natural and pure as 
possible. We also make candles. We have a very 
green and ethical stance when it comes to 
packaging - we use recycled paper with seeds in 
it, and encourage people to plant them in the 
garden after use. 

What's the secret to being a great 
pharmacist? Taking the time to think about 
what you're trying to do in the job - which is 
about helping patients with their medicines 
and health. 

What question should we ask the next 
interviewee? What would be your ideal holiday 

Calling all pharmacists and technicians. We 
want you to be our reader of the week. Email 
us at 

@The Web Hunter 

A dictionary would define a community as 
something like: 'a social group of any size whose 
members reside in a specific locality, share 
government, and often have a common cultural 
and historical heritage or have a similar character, 
agreement, identity, or community of interests.' 

As a publication we have a community - our 
readership. And what we want to be - especially 
online - is a forum for community pharmacists, 
pharmacists in general and pharmacy staff. 

To do this, we can't operate in the way that has 
led to the downfall of many specialist media titles, 
which is to decide what their readership should 
think and churn out editorial based on a misplaced 
sense of 'mother knows best'. On the contrary, 
these days specialist (and I'm avoiding the word 
'niche') publications need to be actively involved 
with their readership and, more importantly, listen 
to them. 

We need to campaign on your behalf, stand up 
for what you believe in and, if you need it, give 
you somewhere to come to discuss your problems 
with like-minded individuals. 

This can be achieved in several different ways. 
One is a conference, where you can come to listen 
to experts and share your concerns. 

Another way - more avant garde this time - is 
to use social media on the wonderful world of 
web. We have a website, where we encourage you 
to leave comments, and use Twitter, Facebook and 
now Linked In. Why Linked In? Well, it is a great 
site for networking; it is a lot more professional 
than Facebook; it lets members of groups start 
their own discussions - oh and you might find 
your next job through it (but don't tell your boss). 
So why not give it a go? Join our Linked In group 
and see what you think. Co to 

Niall Hunt is C+D's digital content editor; 
email him at 

C+D's week in tweets 

@ChemistDruggist: C+D team competition hots 
up for tweet mention on Postscript. 
@CaryParagpuri is very competitive about it ;-) 

@DoncasterLPC: @ChemistDruggist - as the 1st 
LPC to tweet how about us??? 

@ChemistDruggist: @DoncasterLPC -The first 
LPC to tweet is not good enough. Give us a good 
tweet and we shall see! 

@GaryParagpuri: My favourite movie line is: "I'm 
Spartacus." Go on, you know you want to say it 
out loud. 


Two new courses 
for pharmacy staff 
from C+D 

New starter? Want to get them off to a good start but 
without having to put them onto a medicines counter 
assistant's course straight away? 

Counterstart is an induction course for new pharmacy counter staff that will equip 
them with the basic knowledge required to work in a pharmacy safely. 

The course covers: 

My pharmacy and the pharmacy team 
Customer service 

1 Privacy 
• Safety at work 
1 Selling medicines safely 
1 Dealing with prescriptions. 

supported by 

r Reckitt 

For just £15 (ex. VAT) you can ensure your new staff have a basic training - 
plus you can save £5 on their medicine counter assistant's course 

Do you want your counter staff to process dispensary 
stock orders? Need an RPSCB accredited dispensary 
stock management course? 

Stockcheck is an RPSGB accredited dispensary stock management course for 
pharmacy staff who process dispensary stock orders. 

Stockcheck covers the following areas: 

• The dispensary 

• Different types of medicines 
® Ordering & reordering stock 

• Receiving stock 

• Storing stock safely. 



C+D Dispensary Stock 
Management Course 

Student Book 


For just £40 (ex. VAT) you can ensure your pharmacy staff are fully trained 
to provide stock management in the dispensary 

For more information go to, 
or call 0207 921 8425 



A new OTC constipation treatment 
that takes water where it's needed 

Dulcobalance® is a new product from the makers of Dulcolax® 
It dissolves in a glass of water then directs it to the bowel, 
where it works only on the stool. Dulcobalance®, which 
contains macrogol, is not absorbed into the body but uses 
natural osmosis to bind water directly with the stool. Plus, 
its specific mode of action limits bloating and flatulence. 1,2 
Dulcobalance® does not thicken in the glass and has a 
pleasant fruit flavour. As it contains no electrolytes, it is 
suitable for people with cardiovascular or kidney problems. 



macrogol 4000 
lOg powder 

Gentle and effective relief 
from constipation 

• Hydrating action 

i Promotes your natural rhythm 

» Dissolves in water 

i Flavoured with fruit juke 

Body-Friendly Solution for Constipation 

Dulcobalance* Product Information Presentation: Dulcobalance containing lOg of macrogol 4000 
in a sachet. Dulcobalance containing 1 0g of macrogol 4000 in a sachet. Indication: Symptomatic 
treatment of constipation in adults and children aged 8 years and above. Dosage: 1 to 2 sachets 
dissolved in water per day, prefeiably taken as a single dose in the morning. In children treatment should 
not exceed 3 months. Contraindications: Severe inflammatory bowel disease (e.g. ulcerative colitis, 
Crohn's disease), or toxic megacolon associated with symptomatic stenosis, digestive perforation or 
risk of digestive perforation, ileus or suspicion of intestinal obstruction, painful abdominal syndromes of 
indeterminate cause, hypersensitivity to macrogol or any of the excipients. Warnings and precautions: 
Patients with hereditary problems of fructose intolerance should not take Dulcobalance. In case of 
diarrhoea, caution should be exercised in patients who are prone to a disturbance of water electrolyte 
balance (e.g. the elderly, patients with impaired hepatic or renal function or patients taking diuretics). 

Pregnancy and lactation: No data is available in pregnant women, therefore caution should be 
exercised when taking Dulcobalance during pregnancy. As macrogol is not significantly absorbed, 
Dulcobalance may be taken during lactation. Adverse effects: Common: abdominal distension and 
pain, nausea, diarrhoea. Uncommon: vomiting, urgency to defaecate, faecal incontinence and bloating. 
Very rare: Hypersensitivity reactions including pruritus, urticaria, rash, face oedema, Quincke oedema 
ana an isolated case of anaphylactic shock. Unknown: Diarrhoea leading to electrolyte disorders 
(hyponatremia, hypokalemia) and dehydration. RRP (ex VAT): £4.88, 10 sachets Legal category: 
P Product Licence Number: PL 00015/0318 Product Licence Holder: Boehringer Ingelheim Ltd., 
Ellesfield Avenue, Bracknell, Berkshire RG12 8YS. Date of revision: November 2009. 
References: 1. DiPalma JA etal. Overnight Efficacy of Polyethylene Glycol Laxative. Am J Gastroenterol 
2002; 97: 1776-9. 2. Data on file.